Screening and decolonization of MRSA among joint arthroplasty patients: efficacy, cost-effectiveness and durability

Department of Orthopedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain

Screening and decolonization of MRSA among joint arthroplasty patients: efficacy, cost-effectiveness and durability

E. Carlos Rodriguez-Merchan

Department of Orthopedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain

Objective: To review the literature with the aim of answering the following three questions: 1) Is screening and decolonization effective in reducing the rate of infection after elective joint arthroplasty? 2) Is screening and decolonization cost-effective? 3) What is the durability of decolonization?

Methods: The search engines were MedLine (PubMed), Google Scholar and the Cochrane Library. The keywords used were: preoperative MRSA screening. Seven thousand nine hundred and forty eight articles were found until 30 September 2014 (seven thousand eight hundred and fifty in Google Scholar, ninety-seven in MedLine and one in the Cochrane Library). Of those, only eighteen were selected and reviewed because they were strictly focused on the question of this article.

Results: The types of studies reported have a low level of evidence. Most of them are prospective case series, although some of them are systematic reviews of level III studies. There is a tendency toward fewer MRSA infections after elective joint arthroplasty. Decolonization has shown to be strongly cost-effective with 33% of postoperative arthroplasty patients tests positive forStaphylococcus aureuscolonization at 3 to 30 months after surgery.

Conclusions: There is a tendency toward fewer MRSA infections after total joint arthroplasty when screening and decolonization is used. Decolonization is strongly cost-effective procedure with 33% of patients tests positive for MRSA 3 to 30 months after surgery. Larger, randomized, controlled studies are needed to confirm the apparent efficacy of decolonization.

ARTICLE INFO

Article history:

Received 19 Dec 2014

Received in revised form 2014

Accepted 2014

Available online 2014

Joint arthroplasty

Staphylococcus aureus

Postoperative infection

Screening and decolonization

Efficacy

Cost-effectiveness

Durability

1. Introduction

Staphylococcus aureus(S. aureus) is the most common organism responsible for orthopaedic surgical site infections (SSIs) after elective joint arthroplasty. Patients who are carriers for methicillin resistantS. aureus(MRSA) have a higher likelihood of having invasive MRSA infections[1].

Some reports have suggested that screening and decolonization of all patients having elective joint arthroplasty will decrease the incidence of postoperative infections[2]. They believe that a prescreening program (nasal swab using polymerase chain reaction-based testing), followed by an appropriate eradication using a 5- to 14-d course of nasal mucopirocin (2% nasal ointment) will lower the rate of SSIs[3].

Although some have advocated screening and decolonization[3,4], it is unclear whether these efforts reduce SSIs[1]. In other words, while some institutions and surgeons have implemented universal screening and decolonization on their patients undergoing elective arthroplasty, others remain unconvinced about the efficacy of this process[5].

The purpose of this article is to revise the literature with the aim of answering the following three questions: 1) Is screening and decolonization of MRSA effective in reducing the incidence of postoperative infection after elective joint arthroplasty? 2) Is decolonization cost-effective? 3) What is the durability of decolonization?

2. Materials and methods

A review has been performed on the role of screening and decolonization of MRSA in reducing the incidence of postoperative infection after elective joint arthroplasty. The keywords used were: preoperative MRSA screening. The search engines were MedLine (PubMed), Google Scholar and the Cochrane Library. Seven thousand eight hundred and forty eight articles were found until 30 September 2014 (seven thousand eight hundred and fifty in Google Scholar, ninety-seven in MedLine and one in the Cochrane Library). Of those, only eighteen were selected and reviewed because they were strictly focused on the question of this article.

3. Results

The types of studies reported have a low level of evidence (level III, level IV). Most of them are prospective case series (level IV), although some of them are systematic reviews of level III studies. A survey reported by Diekemaet al.showed that only 60% of physicians reported preoperative screening forS. aureus[6]. The incidence of nasal carries of MRSA reported in the orthopaedic literature is very variable, ranging from 1.10% to 25.00% (Table 1)[3,7-14].

Table 1 Incidence of nasal carriers of MRSA and reduction of the rate of SSI in elective joint arthroplasty.

Regarding the efficacy of decolonization, the orthopaedic literature has shown a tendency toward fewer MRSA infections after total joint arthroplasty (Table 1). In the study of Mehtaet al.before implementation of screening and decolonization there was a prevalence density rate (MRSA-positive cultures) of 1.23 per 1000 patient-days. After screening and decolonization, the rate was 0.83 per 1000 patient-days[15].

Two reports have shown that preoperative screening and decolonization of MRSA is strongly cost-effective (incremental cost-effectiveness ratio less than $6 000 per quality-adjusted life year) from the third-party payer perspective even when MRSA prevalence was as low as 1%, decolonization success was as low as 25%, and decolonization costs were as high as $300 per patient[16]. In most scenarios this strategy was economically dominant (i.e., less costly and more effective than no screening). Routine preoperative screening and decolonization of patients undergoing elective joint arthroplasty may under many circumstances save hospitals and third-party payers money while providing health benefits. Sloveret al.conducted a Markov decision analysis to assess the cost savings associated with a preoperative MRSA screening and decolonization program on hip and knee arthroplasties[17]. They concluded that universal MRSA screening and decolonization for hip and knee arthroplasty patients needs to result in only a modest reduction in the SSI rate to be cost saving.

Concerning the durability of decolonization, arthroplasty surgeons must be aware that a decolonization treatment does not guarantee that a patient will remain decolonized in the future[18]. In a study, 33% of postoperative arthroplasty patients tested positive for MRSA colonization at 3 to 30 months after surgery despite preoperative decolonization[18].

4. Discussion

The purpose of this article was to review the literature after 2008 with the aim of answering the following the following three questions: 1) Is screening and decolonization of MRSA effective in reducing the rate of postoperative infection after elective joint arthroplasty? 2) Is decolonization costeffective? 3) What is the durability of decolonization?

The quality of studies reported so far on the topic is poor (low level of evidence, level III, level IV). Most of them are prospective case series (level IV), although some are systematic reviews of level III studies[1-18].

In a survey only 60% of physicians reported preoperative screening forS. aureus[6]. The incidence of nasal carries of MRSA in the orthopaedic literature is very variable, ranging from 1.10% to 25.00%[4,7-14].

Regarding the efficacy of decolonization, a reduction of the incidence of postoperative SSI after elective joint arthroplasty has been found in the literature. The prevalence density rate (MRSA-positive cultures) of 1.23 per 1000 patient-days before decolonization dropped to 0.83 per 1000 patient-days after decolonization[14].

Preoperative MRSA screening and decolonization is strongly cost-effective (incremental cost-effectiveness ratio less than $6 000 per quality-adjusted life year) from the third-party payer perspective even when MRSA prevalence was as low as 1%, decolonization success was as low as 25%, and decolonization costs were as high as $300 per patient[16].A Markov decision analysis showed that universal S. aureusscreening and decolonization for hip and knee arthroplasty patients needs to result in only a modest reduction in the SSI rate to be cost saving.

Concerning the durability of decolonization, arthroplasty surgeons must be aware that a decolonization treatment does not guarantee that a patient will remain decolonized in the future[18]. In a study, 33% of postoperative arthroplasty patients tested positive for MRSA colonization at 3 to 30 months after surgery despite preoperative decolonization[18].

In conclusion, the review of the literature found a tendency toward fewer MRSA SSIs after total joint arthroplasty when a screening and decolonization program was used. However, most of these studies were underpowered. Larger, randomized, controlled studies are needed to confirm the apparent efficacy of decolonization. Screening and decolonization is a cost-effective procedure. Regarding the durability of decolonization, one third of patients tested are positive for S. aureus at 3 to 30 months after surgery.

Conflict of interest statement

The author declare that there are no conflicts of interest.

[1] Chen AF, Wessel CB, Rao N. Staphylococcus aureus screening and decolonization in orthopaedic surgery and reduction of surgical site infections. Clin Orthop Relat Res 2013; 471(7): 2383-2399.

[2] Shams WE, Rapp RP. Methicillin-resistant staphylococcal infections: an important consideration for orthopedic surgeons. Orthopedics 2004; 27(6): 565-568.

[3] Savage JW, Anderson PA. An update on modifiable factors to reduce the risk of surgical site infections. Spine J 2013; 13(9): 1017-1029.

[4] Glassner PJ, Slover JD, Bosco JA 3rd, Zuckerman JD. Blood, bugs, and motion - what do we really know in regard to total joint arthroplasty? Bull NYU Hosp Jt Dis 2011; 69(1): 73-80.

[5] Parvizi J. CORR insights®: Staphylococcus aureus colonization among arthroplasty patients previously treated by a decolonization protocol: a pilot study. Clin Orthop Relat Res 2013; 471: 3133-3134.

[6] Diekema D, Johannsson B, Herwaldt L, Beekmann S, Jernigan J, Kallen A, et al. Current practice in Staphylococcus aureus screening and decolonization. Infect Control Hosp Epidemiol 2011; 32(10): 1042-1044.

[7] Price CS, Williams A, Philips G, Dayton M, Smith W, Morgan S. Staphylococcus aureus nasal colonization in preoperative orthopaedic outpatients. Clin Orthop Relat Res 2008; 466(11): 2842-2847.

[8] Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF. Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg 2009; 208(5): 981-988.

[9] Bajolet O, Toussaint E, Diallo S, Vernet-Garnier V, Dehoux E. [Is it possible to detect Staphylococcus aureus colonization or bacteriuria before orthopedic surgery hospitalization?].[Article in French] Pathol Biol (Paris) 2010; 58(2): 127-130. French.

[10] Hadley S, Immerman I, Hutzler L, Slover J, Bosco J. Staphylococcus aureus decolonization protocol decreases surgical site infections for total joint replacement. Arthritis 2010; doi: 10.1155/2010/924518.

[11] Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, 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(9): 1820-1826.

[12] Gupta K, Strymish J, Abi-Haidar Y, Williams SA, Itani KM. Preoperative nasal methicillin-resistant Staphylococcus aureus status, surgical prophylaxis, and risk-adjusted postoperative outcomes in veterans. Infect Control Hosp Epidemiol 2011; 32(8): 791-796.

[13] Kelly JC, O’Briain DE, Walls R, Lee SI, O’Rourke A, Mc Cabe JP. The role of pre-operative assessment and ringfencing of services in the control of methicillin resistant Staphlococcus aureus infection in orthopaedic patients. Surgeon 2012; 10(2): 75-79.

[14] Chen AF, Heyl AE, Xu PZ, Rao N, Klatt BA. Preoperative decolonization effective at reducing staphylococcal colonization in total joint arthroplasty patients. J Arthroplasty 2013; 28(8 Suppl): 18-20.

[15] Mehta S, Hadley S, Hutzler L, Slover J, Phillips M, Bosco JA 3rd. Impact of preoperative MRSA screening and decolonization on hospital-acquired MRSA burden. Clin Orthop Relat Res 2013; 471(7): 2367-2371.

[16] Lee BY, Wiringa AE, Bailey RR, Goyal V, Tsui B, Lewis GJ, et al. The economic effect of screening orthopedic surgery patients preoperatively for methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2010; 31(11): 1130-1138.

[17] Slover J, Haas JP, Quirno M, Phillips MS, Bosco JA 3rd. Cost-effectiveness of a Staphylococcus aureus screening and decolonization program for high-risk orthopedic patients. J Arthroplasty 2011; 26(3): 360-365.

[18] Economedes DM, Deirmengian GK, Deirmengian CA. Staphylococcus aureus colonization among arthroplasty patients previously treated by a decolonization protocol: a pilot study. Clin Orthop Relar Res 2013; 471: 3128-3132.

ment heading

10.1016/S2221-6189(14)60048-2

*Corresponding author: Prof. E. Carlos Rodriguez-Merchan, Department of Orthopedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046-Madrid, Spain.

E-mail: ecrmerchan@gmx.es