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      Reduction of periprosthetic Staphylococcus aureus infection by preoperative screening and decolonization of nasal carriers undergoing total knee arthroplasty

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          Abstract

          Objective

          The aim of this study was to evaluate whether the establishment of a preoperative screening and decolonization protocol for Staphylococcus aureus carriers undergoing total knee arthroplasty (TKA) could decrease the incidence of periprosthetic joint infection (PJI) caused by this microorganism.

          Methods

          We conducted a retrospective study comparing a control group comprising 400 patients (134 men, and 266 women; mean age: 72.2 ± 6.8 years) who went through surgery between January 2009 and December 2013, with a second intervention group of 403 patients (125 men, and 278 women; mean age: 72.4 ± 6.9 years) in which the protocol of screening and decolonization of S. aureus nasal carriers was applied between January 2014 and December 2016. During this latter period patients were preoperatively screened and, if positive, treated with mupirocin nasal ointment and chlorhexidine soap, for 5 days prior to surgery.

          Results

          In the control group, 17 of 400 patients (4.2%) had a SSI, 8 (2%) of them caused by S. aureus and 9 (2.2%) by other microorganisms. In the intervention group 20.6% of patients had a positive S. aureus nasal swab and were treated according to the protocol. 5 of 403 patients (1.2%) in this group had a SSI, 1 (0.2%) due to S. aureus and 4 (1%) to other microorganisms. When comparing surgical-site infection (SSI) rates between the two groups, we found a statistically significant reduction in both global SSI (p = 0.009) and specifically S. aureus SSI (p = 0.02), in the intervention group. No decolonized S. aureus nasal carrier presented a SSI.

          Discussion

          In patients undergoing TKA a preoperative screening and decolonization protocol for S. aureus nasal carriers, using mupirocin nasal ointment and chlorhexidine soap, is an effective measure to reduce the rate of SSI caused by this microorganism.

          Level of Evidence

          Level III; Therapeutic Study.

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          Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.

          Lonneke G M Bode, Jan Kluytmans, Heiman Wertheim … (2010)
          Nasal carriers of Staphylococcus aureus are at increased risk for health care-associated infections with this organism. Decolonization of nasal and extranasal sites on hospital admission may reduce this risk. In a randomized, double-blind, placebo-controlled, multicenter trial, we assessed whether rapid identification of S. aureus nasal carriers by means of a real-time polymerase-chain-reaction (PCR) assay, followed by treatment with mupirocin nasal ointment and chlorhexidine soap, reduces the risk of hospital-associated S. aureus infection. From October 2005 through June 2007, a total of 6771 patients were screened on admission. A total of 1270 nasal swabs from 1251 patients were positive for S. aureus. We enrolled 917 of these patients in the intention-to-treat analysis, of whom 808 (88.1%) underwent a surgical procedure. All the S. aureus strains identified on PCR assay were susceptible to methicillin and mupirocin. The rate of S. aureus infection was 3.4% (17 of 504 patients) in the mupirocin-chlorhexidine group, as compared with 7.7% (32 of 413 patients) in the placebo group (relative risk of infection, 0.42; 95% confidence interval [CI], 0.23 to 0.75). The effect of mupirocin-chlorhexidine treatment was most pronounced for deep surgical-site infections (relative risk, 0.21; 95% CI, 0.07 to 0.62). There was no significant difference in all-cause in-hospital mortality between the two groups. The time to the onset of nosocomial infection was shorter in the placebo group than in the mupirocin-chlorhexidine group (P=0.005). The number of surgical-site S. aureus infections acquired in the hospital can be reduced by rapid screening and decolonizing of nasal carriers of S. aureus on admission. (Current Controlled Trials number, ISRCTN56186788.) 2010 Massachusetts Medical Society
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            Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.

            Krystin Ambrose, Rajiv Jain, R Freyberg … (2011)
            Health care-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) have been an increasing concern in Veterans Affairs (VA) hospitals. A "MRSA bundle" was implemented in 2007 in acute care VA hospitals nationwide in an effort to decrease health care-associated infections with MRSA. The bundle consisted of universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients. Each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and health care-associated transmissions of and infections with MRSA. We assessed the effect of the MRSA bundle on health care-associated MRSA infections. From October 2007, when the bundle was fully implemented, through June 2010, there were 1,934,598 admissions to or transfers or discharges from intensive care units (ICUs) and non-ICUs (ICUs, 365,139; non-ICUs, 1,569,459) and 8,318,675 patient-days (ICUs, 1,312,840; and non-ICUs, 7,005,835). During this period, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. The mean (±SD) prevalence of MRSA colonization or infection at the time of hospital admission was 13.6±3.7%. The rates of health care-associated MRSA infections in ICUs had not changed in the 2 years before October 2007 (P=0.50 for trend) but declined with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P<0.001 for trend). During this same period, the rates of health care-associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P<0.001 for trend). A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care-associated transmissions of and infections with MRSA in a large health care system.
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              Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections.

              , David French, Jennifer Twombley … (2002)
              Patients with nasal carriage of Staphylococcus aureus have an increased risk of surgical-site infections caused by that organism. Treatment with mupirocin ointment can reduce the rate of nasal carriage and may prevent postoperative S. aureus infections. We conducted a randomized, double-blind, placebo-controlled trial to determine whether intranasal treatment with mupirocin reduces the rate of S. aureus infections at surgical sites and prevents other nosocomial infections. Of 4030 enrolled patients who underwent general, gynecologic, neurologic, or cardiothoracic surgery, 3864 were included in the intention-to-treat analysis. Overall, 2.3 percent of mupirocin recipients and 2.4 percent of placebo recipients had S. aureus infections at surgical sites. Of the 891 patients (23.1 percent of the 3864 who completed the study) who had S. aureus in their anterior nares, 444 received mupirocin and 447 received placebo. Among the patients with nasal carriage of S. aureus, 4.0 percent of those who received mupirocin had nosocomial S. aureus infections, as compared with 7.7 percent of those who received placebo (odds ratio for infection, 0.49; 95 percent confidence interval, 0.25 to 0.92; P=0.02). Prophylactic intranasal application of mupirocin did not significantly reduce the rate of S. aureus surgical-site infections overall, but it did significantly decrease the rate of all nosocomial S. aureus infections among the patients who were S. aureus carriers.
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                Author and article information

                Contributors
                Xavier Pelfort
                Alba Romero
                Montserrat Brugués
                Amparo García
                Sergi Gil
                Anna Marrón
                Journal
                Journal ID (nlm-ta): Acta Orthop Traumatol Turc
                Journal ID (iso-abbrev): Acta Orthop Traumatol Turc
                Title: Acta Orthopaedica et Traumatologica Turcica
                Publisher: Turkish Association of Orthopaedics and Traumatology
                ISSN (Print): 1017-995X
                ISSN (Electronic): 2589-1294
                Publication date PMC-release: 16 September 2019
                Publication date (Print): November 2019
                Publication date (Electronic): 16 September 2019
                Volume: 53
                Issue: 6
                Pages: 426-431
                Affiliations
                [a ]Department of Orthopaedics and Trauma, Consorci Sanitari de l'Anoia - Hospital d'Igualada, Barcelona, Spain
                [b ]Hospital Universitari Quirón-Dexeus, ICATME - EQUILAE, Barcelona, Spain
                [c ]Department Nosocomial Infection, Consorci Sanitari de l'Anoia - Hospital d’Igualada, Barcelona, Spain
                [d ]Department of Microbiology, Consorci Sanitari de l'Anoia - Hospital d’Igualada, Barcelona, Spain
                [e ]Department of Internal Medicine, Consorci Sanitari de l'Anoia - Hospital d’Igualada, Barcelona, Spain
                Author notes
                [∗ ]Corresponding author. Department of Orthopaedics and Trauma, Consorci Sanitari de l’Anoia - Hospital d’Igualada, Barcelona, Spain. Tel.: +34 606674861; fax: +34 938075537. xavierpelfortlopez@ 123456gmail.com
                Article
                Publisher ID: S1017-995X(19)30389-X
                DOI: 10.1016/j.aott.2019.08.014
                PMC ID: 6938997
                PubMed ID: 31537434
                SO-VID: 93adf014-7ca2-4709-879b-3eaf22903e56
                Copyright © © 2019 Turkish Association of Orthopaedics and Traumatology. Publishing services by Elsevier B.V.
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 9 August 2018
                Date revision received : 12 April 2019
                Date accepted : 26 August 2019
                Categories
                Subject: Research Article

                Keywords: s. aureus,tka infection,screening protocol,decolonization protocol,tkr infection
                Data availability:
                Keywords: s. aureus, tka infection, screening protocol, decolonization protocol, tkr infection

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