Modified Protocol Decreases Surgical Site Infections after Total Knee Arthroplasty

Abstract

We investigate the effectiveness of a comprehensive aseptic protocol in reducing surgical site infection (SSI) after knee arthroplasty in a single medical center with a high prevalence of MRSA. A database of all patients in a single center undergoing primary knee arthroplasty between 2005 and 2011 was reviewed for SSI using Centers for Disease Control criteria and AAOS guidelines. All patients were treated with an aseptic protocol consisting of the following: preoperative 2% mupirocin nasal ointment and 0.4% chlorhexidine surgical site wipes, modified instrument care, perioperative prophylactic vancomycin and cefazolin, and surgical site skin preparation with chlorhexidine, alcohol, and iodophor. We compare our protocol total knee arthroplasty SSI rate to our institutional historical control (2001–2004) and to contemporary literature. Among 1,224 patients, 70% were ASA class >2 and 64% had a body mass index (BMI) > 30 kg/m². We found an overall 0.49% infection rate, significantly lower than that of our institutional historical control (0.49 vs. 2.24%, p < 0.001; odds ratio [OR], 0.21; number needed to treat [NNT], 145) and seven recently published reports (p < 0.001–0.042; OR, 0.07–0.42). Compared with these reports, significantly more of our patients were ASA class > 2, BMI > 30 kg/m², immunosuppressed, or had rheumatoid arthritis. Our aseptic protocol decreases SSI in a high-risk population undergoing knee arthroplasty in a medical center and community with a high prevalence of MRSA.

Keywords

surgical site infection - aseptic protocol - total knee arthroplasty - antibiotic prophylaxis

• References

• 1 Deirmengian CA, Lonner JH. What's new in adult reconstructive knee surgery. J Bone Joint Surg Am 2008; 90 (11) 2556-2565
• 2 Bhandari M, Smith J, Miller LE, Block JE. Clinical and economic burden of revision knee arthroplasty. Clin Med Insights Arthritis Musculoskelet Disord 2012; 5: 89-94
• 3 Bozic KJ, Lau E, Kurtz S, Ong K, Berry DJ. Patient-related risk factors for postoperative mortality and periprosthetic joint infection in Medicare patients undergoing TKA. Clin Orthop Relat Res 2012; 470 (1) 130-137
• 4 Bozic KJ, Kurtz SM, Lau E , et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res 2010; 468 (1) 45-51
• 5 Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012; 27 (8, Suppl): 61-5.e1
• 6 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (4) 780-785
• 7 Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009; 91 (1) 128-133
• 8 Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010; 468 (1) 52-56
• 9 Ong KL, Kurtz SM, Lau E, Bozic KJ, Berry DJ, Parvizi J. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplasty 2009; 24 (6, Suppl): 105-109
• 10 Berbari EF, Osmon DR, Lahr B , et al. The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification. Infect Control Hosp Epidemiol 2012; 33 (8) 774-781
• 11 Everhart JSAE, Altneu E, Calhoun JH. Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 2013; 471 (10) 3112-3119
• 12 Blom AW, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Infection after total hip arthroplasty. The Avon experience. J Bone Joint Surg Br 2003; 85 (7) 956-959
• 13 Jämsen E, Huhtala H, Puolakka T, Moilanen T. Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases. J Bone Joint Surg Am 2009; 91 (1) 38-47
• 14 Jämsen E, Varonen M, Huhtala H , et al. Incidence of prosthetic joint infections after primary knee arthroplasty. J Arthroplasty 2010; 25 (1) 87-92
• 15 Levent T, Vandevelde D, Delobelle JM , et al. Infection risk prevention following total knee arthroplasty. Orthop Traumatol Surg Res 2010; 96 (1) 49-56
• 16 Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 2008; 466 (7) 1710-1715
• 17 Song KH, Kim ES, Kim YK , et al. Differences in the risk factors for surgical site infection between total hip arthroplasty and total knee arthroplasty in the Korean Nosocomial Infections Surveillance System (KONIS). Infect Control Hosp Epidemiol 2012; 33 (11) 1086-1093
• 18 Willis-Owen CA, Konyves A, Martin DK. Factors affecting the incidence of infection in hip and knee replacement: an analysis of 5277 cases. J Bone Joint Surg Br 2010; 92 (8) 1128-1133
• 19 Dowsey MM, Choong PF. Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty. Clin Orthop Relat Res 2008; 466 (1) 153-158
• 20 Bongartz T, Halligan CS, Osmon DR , et al. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 2008; 59 (12) 1713-1720
• 21 Ridgeway S, Wilson J, Charlet A, Kafatos G, Pearson A, Coello R. Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg Br 2005; 87 (6) 844-850
• 22 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 (2) 94-101
• 23 Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 2009; 24 (6, Suppl): 84-88
• 24 Namba RS, Inacio MC, Paxton EW. Risk factors associated with surgical site infection in 30,491 primary total hip replacements. J Bone Joint Surg Br 2012; 94 (10) 1330-1338
• 25 David MZ, Glikman D, Crawford SE , et al. What is community-associated methicillin-resistant Staphylococcus aureus?. J Infect Dis 2008; 197 (9) 1235-1243
• 26 Herold BC, Immergluck LC, Maranan MC , et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998; 279 (8) 593-598
• 27 Centers for Disease Control. Surgical Site Infection (SSI) Event. 2014. Available at: www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf
• 28 Parvizi J. New definition for periprosthetic joint infection. Am J Orthop 2011; 40 (12) 614-615
• 29 Chesney D, Sales J, Elton R, Brenkel IJ. Infection after knee arthroplasty a prospective study of 1509 cases. J Arthroplasty 2008; 23 (3) 355-359
• 30 Jodrá VM, Díaz-Agero Pérez C, Sainz de Los Terreros Soler L, Saa Requejo CM, Dacosta Ballesteros D ; Quality Control Indicator Working Group. Results of the Spanish national nosocomial infection surveillance network (VICONOS) for surgery patients from January 1997 through December 2003. Am J Infect Control 2006; 34 (3) 134-141
• 31 Manniën J, van den Hof S, Muilwijk J, van den Broek PJ, van Benthem B, Wille JC. Trends in the incidence of surgical site infection in the Netherlands. Infect Control Hosp Epidemiol 2008; 29 (12) 1132-1138
• 32 Webb BG, Lichtman DM, Wagner RA. Risk factors in total joint arthroplasty: comparison of infection rates in patients with different socioeconomic backgrounds. Orthopedics 2008; 31 (5) 445
• 33 Song KH, Kang YM, Sin HY , et al. Outcome of cefazolin prophylaxis for total knee arthroplasty at an institution with high prevalence of methicillin-resistant Staphylococcus aureus infection. Int J Infect Dis 2011; 15 (12) e867-e870
• 34 Sewick A, Makani A, Wu C, O'Donnell J, Baldwin KD, Lee GC. Does dual antibiotic prophylaxis better prevent surgical site infections in total joint arthroplasty?. Clin Orthop Relat Res 2012; 470 (10) 2702-2707
• 35 Bode LG, Kluytmans JA, Wertheim HF , et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010; 362 (1) 9-17
• 36 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 (2) 152-159
• 37 Garvin KL, Konigsberg BS. Infection following total knee arthroplasty: prevention and management. J Bone Joint Surg Am 2011; 93 (12) 1167-1175
• 38 Kim DH, Spencer M, Davidson SM , 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 (9) 1820-1826
• 39 Smith EB, Wynne R, Joshi A, Liu H, Good RP. Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total joint arthroplasty patients?. J Arthroplasty 2012; 27 (8, Suppl): 55-60
• 40 Wilcox MH, Hall J, Pike H , et al. Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect 2003; 54 (3) 196-201
• 41 Darouiche RO, Wall Jr MJ, Itani KM , et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362 (1) 18-26
• 42 Crawford T, Rodvold KA, Solomkin JS. Vancomycin for surgical prophylaxis?. Clin Infect Dis 2012; 54 (10) 1474-1479
• 43 Finkelstein R, Rabino G, Mashiah T , 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 (2) 326-332
• 44 David MZ, Boyle-Vavra S, Zychowski DL, Daum RS. Methicillin-susceptible Staphylococcus aureus as a predominantly healthcare-associated pathogen: a possible reversal of roles?. PLoS ONE 2011; 6 (4) e18217
• 45 David MZ, Medvedev S, Hohmann SF, Ewigman B, Daum RS. Increasing burden of methicillin-resistant Staphylococcus aureus hospitalizations at US academic medical centers, 2003-2008. Infect Control Hosp Epidemiol 2012; 33 (8) 782-789
• 46 Meehan J, Jamali AA, Nguyen H. Prophylactic antibiotics in hip and knee arthroplasty. J Bone Joint Surg Am 2009; 91 (10) 2480-2490
• 47 Anderson DJ, Kaye KS, Classen D , et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29 (Suppl. 01) S51-S61
• 48 Phillips JE, Crane TP, Noy M, Elliott TS, Grimer RJ. The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Joint Surg Br 2006; 88 (7) 943-948