0
    634
    views

    Infection Prevention for Total Joint Arthroplasty: Pros and Cons

    The authors closely examine the evidence for measures that can be taken to reduce the risk of infection during the preoperative, intraoperative, and postoperative periods.

    Authors

    Kevin Chen, MA; Ameer Elbuluk, BA; Samir Nayyar, MD; Duke Hasson, MD; Ran Schwarzkopf, MD MSc; and Jonathan Vidgorchik, MD

    Disclosures

    The authors have no disclosures relevant to this article.

    Introduction

    Infection remains one of the most common and costly complications following total joint arthroplasty (TJA). [1] It is currently the leading cause of revision total knee arthroplasty (TKA) and the third most common cause of revision total hip arthroplasty (THA) in the United States. [2,3]

    Despite the development of several preventative measures, the rate of infection continues to be approximately 1% for patients undergoing TKA and THA [4] The extent of the infection can range from a mild superficial infection to a more serious periprosthetic joint infection (PJI).

    Periprosthetic joint infections not only play a significant role in the clinical well-being of the TJA patient population, but they also have economic implications on the healthcare system. Infection results in increased [5,6]:

    • Length of stay (LOS)
    • Readmission rates
    • Need for medical interventions

    With a projected increase in TKA and THA of 673% and 174%, respectively, by 2030, limiting complications such as PJI will be paramount to maintaining the viability of these procedures. [7]
     
    Many approaches are currently being used to mitigate the risk of PJI following TJA, with newer approaches constantly being developed. Accordingly, the variety of prophylactic agents created to prevent infection after TJA must be thoroughly discussed and evaluated.

    For the purposes of discussion, these methods can be divided into preoperative, intraoperative, and postoperative measures. In this review, we will thoroughly examine the opportunities for infection prevention during each of these transitions of care.

    Preoperative Measures

    MRSA and Staphyloccocus Screening and Decolonization

    Staphylococcus aureus is the organism found to have the highest association with surgical site infection (SSI) following TJA. It has been reported to colonize the nasal area in nearly 33% of the population. [8-10]

    As such, many studies have examined the impact of minimizing colonization and population density of methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) in patients undergoing TJA.

    A systematic review by Chen et al [11] examined 19 studies that evaluated the effectiveness of various S. aureus decolonization protocols in reducing SSIs in patients undergoing TJA. Each study substantiated the evidence that S. aureus screening and decolonization (with the use of mupirocin alone or in combination of other agents) is an effective means of reducing SSI. [11]

    Furthermore, these models showed that implementing an S. aureus decolonization protocol is an economically preferred strategy compared with non-treatment. For example, Courville et al [12] demonstrated a savings of $330 per quality-adjusted life year (QALY) in THA and $438 saved per QALY for TKA when all patients were decolonized compared with patients who were not treated.
     
    However, as intranasal screening and treatment have become more widespread, the benefits of these programs must be carefully weighed against the economic and clinical implications of routine screening and decolonization.

    In a retrospective evaluation, Torres et al [13] evaluated povidone-iodine nasal swabs and MRSA screening in 1,853 TJA patients to determine their impact on the incidence of SSI at 90 days.

    Without screening for S. aureus, they found that a povidone-iodine swab and chlorhexidine bath for 5 days leading up to surgery had the same efficacy in limiting infections as a 5-day dose of mupirocin and CHG bathing (0.8%). This povidine-iodine protocol also allowed for cost savings of $93.35 per patient (P<0.01). [13]

    Thus, although screening and decolonization protocols have the benefit of clinical and economic evidence in their favor, it is important to recognize that clinically non-inferior alternatives such as a povidine-iodine protocol may also be financially favorable.

    Chlorhexidine Shower

    Whole-body bathing or showering with chlorhexidine gluconate (CHG), a topical antiseptic, has a demonstrated ability to limit the risk of SSIs and healthcare-associated infections before surgery. [14,15] Moreover, CHG is an affordable option thought to have minimal side effects; except for rare cases of anaphylaxis, side effects are typically limited to localized skin reactions. [16] Studies have documented significantly decreased SSI risk when TJA patients are compliant with the CHG protocol. [17,18]

    In a prospective consecutive series, Johnson et al [18] found that patients who used CHG wipes 1 day prior to THA and the morning of their operation had a lower incidence of SSI (0%) than patients who did not comply (1.6% infection rate) with this protocol. Patients with partial compliance were excluded from the analysis.

    Another study by Kapadia et al [19] examined whether preadmission cutaneous CHG preparations reduced SSI after THA in 2,458 patients. Overall, they found that the use of preoperative CHG cloth skin preparation was associated with a reduced relative risk of SSI after THA when compared with patients undergoing in-hospital perioperative skin preparation only (3/557 or 0.5% compared with 32/1901 or 1.7%; P=0.04). [19]
     
    However, in a meta-analysis by Chlebicki et al, [20] 16 trials comparing a total of 17,932 patients demonstrated no significant reduction in the overall incidence of SSI when comparing hte use of CHG with the use of soap, placebo, or no shower/bathing (RR:0.9; CI: 0.77-1.05; P=0.19).

    Although the authors conceded that many of the included studies had suboptimal designs, this meta-analysis sheds light on the importance of higher-quality randomized trials to fully elucidate its potential benefit. [20]

    Nonetheless, CHG is a relatively affordable and low-risk treatment, and even a marginal clinical benefit may justify its use.

    Antibiotic Stewardship and Dual Antibiotics

    Several clinical studies have shown the added benefit of parenteral prophylactic antibiotics in decreasing the likelihood of SSI. [21,22]

    For orthopaedic procedures, which often incorporate an implant, antibiotics are recommended either before induction of anesthesia or a least 10 minutes before inflation of a tourniquet. The preferred agent has generally been cefazolin, a first-generation cephalosporin that helps to suppress Staphylococcus dermal and incisional infections.

    However, these protocols have been used since the 1960s, with little change or no change in the preoperative prophylactic regimens since that time.

    Furthermore, cefazolin may be inadequate at some institutions because of high rates of MRSA and gram-negative bacilli (GNB). A study by Norton et al, [23] for example, demonstrated that 30% of SSIs following THA were actually caused by GNB.

    With increasing antibiotic resistance and isolates of GNB at their institution, Bosco et al [24] studied the effect of expanded gram-negative antimicrobial prophylaxis (EGNAP) on SSI rates following primary TJA.

    To expand gram-negative antimicrobial prophylaxis, they added weight-based, high-dose gentamicin (or aztreonam if patients had contraindications for gentamicin) to their prophylactic antibiotic protocol for THA and TKA. Their study included 10,084 cases: 5,389 THAs (group 1) and 4,695 TKAs (group 2).

    Before the introduction of EGNAP, the SSI rate for group 1 was 1.19% (49/4122). After July 2012, when EGNAP was added, the overall group 1 SSI rate decreased to 0.55% (7/1267; P=0.05). However, no significant difference in the SSI rates was seen in group 2 during the study period: 1.08% before EGNAP versus 1.02% after EGNAP (P=0.999).

    In addition, there was a significant decrease in gram-positive bacteria SSIs, from 1.01% (41/4,122) to 0.47% (6/1,267) (P=0.05).

    The study demonstrates that the addition of weight-based, high-dose gentamicin or aztreonam for prophylaxis before THA is a safe and effective method for reducing the rate of SSIs.

    A study by Sewick et a1 [25] examined whether dual antibiotic prophylaxis:

    • Reduced the rate of SSI compared with single antibiotic prophylaxis
    • Altered the microbiology of SSI in patients undergoing TJA

    They retrospectively reviewed 1,828 primary THAs and TKAs and divided patients into 2 groups: [25]:

    • Those who received a dual prophylactic antibiotic regimen of cefazolin and vancomycin (unless allergic to these drugs)
    • Those who received cefazolin (unless allergic to this drug) as the sole prophylactic antibiotic

    The infection rates for dual antibiotic prophylaxis compared with a single antibiotic regimen were 1.1% and 1.4%, respectively.

    Sewick et al [25] concluded that the addition of vancomycin as a prophylactic antibiotic agent did not reduce the rate of SSI compared with cefazolin alone, but could reduce the incidence of MRSA infections.

    These studies highlight the importance of establishing a robust institutional SSI surveillance and antibiotic stewardship program. The benefits of such a program can help to elucidate the evolving patterns and virulence of pathogens, which offers institutions an opportunity to establish and implement recommendations to address these changes.

    Intraoperative Measures

    Vancomycin Powder

    Several studies have shown a decreased incidence of deep wound infections with the local use of vancomycin during spine and trauma procedures. [26-29] 

    Schroeder et al [30] examined the use of vancomycin powder into surgical wounds before closing the fascia as a method to reduce deep infection rates in patients undergoing spine procedures. There were 30 cases of deep infections needing surgical irrigation and debridement among ptaients who had not received vancomycin versus 5 cases in patients who had received the drug (P = 0.04). Infections in patients treated with vancomycin were not caused by vancomycin-resistant bacteria.

    The number needed to treat in order to reduce 1 case of deep infection in this study was close to 200. Despite this large number, treatment with local vancomycin has been shown to be a cost-effective measure when compared with the high cost associated with management of a deep infection.

    Wukich et al [31] also examined the efficacy of local vancomycin powder to reduce SSI in patients with diabetes mellitus (DM) undergoing foot and ankle surgery. The 81 patients with DM who underwent reconstructive surgery for a foot and/or ankle deformity and/or trauma and who received topically applied vancomycin were matched to 81 patients with DM who did not receive topically applied vancomycin. The 2 groups were similar with regard to gender, body mass index, duration of DM, short-term and longer term glycemic control, and length of surgery. [31]

    The overall likelihood of SSI was decreased by 73% in patients who received topically applied vancomycin (odds ratio [OR], 0.267; P=0.0188). The rate of superficial infection was not significantly different between groups (OR, 0.400; P = 0.2734), but deep infections were 80% less likely in patients who received vancomycin powder (OR: 0.200; P=0.0377). [31]

    The authors found that high-risk diabetic patients undergoing foot and ankle surgery were notably less likely to develop an SSI (particularly a deep infection) with the use of topically applied vancomycin powder in the surgical wound. With regard to cost, topically applied vancomycin was associated with a very low rate of complications and was inexpensive ($5 per 1000 mg). [31]

    Based on this study, the authors concluded that foot and ankle surgeons may consider applying 500 to 1000 mg of vancomycin powder prior to skin closure in diabetic patients who are not allergic to vancomycin.

    Postoperative Measures

    Wound Dressings

    Wound dressings provide a protective barrier that is critical for minimizing contamination and promoting healing after surgery. When managing a wound, a moist occlusive wound environment is favored over a dry wound environment because it limits desiccation and cellular death. [32-35]

    However, such an environment can also increase the risk of microbial colonization if not properly managed. The most effective wound dressings, therefore, must maintain a moist environment while protecting the incision area from contamination and further damage.

    Multiple dressing types have been developed to achieve this goal. The current literature on the use of wound dressings in TJA patients primarily describes hydrofiber dressings such as Aquacel and Aquacel Ag (ConvaTec, Bridgewater, NJ). [36-41]

    Hydrofiber wound dressings are composed of sodium carboxymethylcelluose and help to maintain a moist environment, which allows for fewer dressing changes with improved wound healing. [42-44] Silver-impregnated hydrofiber dressings (such as Aquacel Ag) also contain ionic silver that acts as a bacteriostatic agent. [36,37,42]

    Studies by Grosso et al [36] and Cai et al [37] have demonstrated strong evidence supporting the use hydrofibre dressings when compared with other types of dressings.

    Grosso et al [36] reviewed 1173 consecutive patient charts in patients undergoing TJA and found that patients in the silver-impregnated hydrofiber dressing group had a significantly decreased the rate of PJI (0.33%) compared with patients in the standard sterile dressing group (1.58%).

    Cai et al [37] reported a retrospective chart review comparing 903 consecutive patients who received a hydrofiber dressing with 875 patients who received a standard dressing. According to the authors, the prevalence of acute PJI was significantly lower in the hydrofiber group (0.44%) than in the standard dressing group (1.71%).

    Together, these studies highlight the potential for infection reduction through the use of hydrofiber dressings. According to Cai’s group, routine use of hydrofiber dressings for TJA patients in the United States would add roughly $27 million in cost. [37] However, the additional cost could be balanced with the savings from reduced readmissions, LOS, and other factors related to management of infection following TJA.

    This premise has been challenged by at least 1 study by Ubbink et al, [45] who compared occlusive, moist-environment dressings with standard gauze-based dressings and found no significant difference in time to complete wound healing.

    Although this study did not look at hydrofiber dressings alone in the occlusive group, it highlights an important consideration in infection prevention: Before any dressing can be routinely recommended, more robust literature is needed to evaluate the true effectiveness.

    Conclusion

    Infection control is an important consideration in all surgical procedures, but especially in TJA procedures, which often incorporate implants and can result in costly revisions.

    Multiple opportunities exist to improve pre-, intra-, and postoperative infection control. Accordingly, each of the interventions in this article must be carefully evaluated to determine their value in preventing this significant complication.

    Overall, this report highlights the importance of infection management and can help to serve as a framework to weigh the pros and cons of infection control at each stage of surgical management.

    Author Information

    Kevin Chen, MA; Ameer Elbuluk, BA; Samir Nayyar, MD; Duke Hasson, MD; Ran Schwarzkopf, MD MSc; and Jonathan Vidgorchik, MD are from the Department of Orthopaedic Surgery,  NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.

    References

    1. Lindeque, B., et al., Infection after primary total hip arthroplasty. Orthopedics, 2014. 37(4): p. 257-65.
    2. Bozic, K.J., et al., The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res, 2010. 468(1): p. 45-51.
    3. Bozic, K.J., et al., The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am, 2009. 91(1): p. 128-33.
    4. Kurtz, S.M., et al., Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty, 2008. 23(7): p. 984-91.
    5. Bozic, K.J. and M.D. Ries, The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am, 2005. 87(8): p. 1746-51.
    6. Sculco, T.P., The economic impact of infected joint arthroplasty. Orthopedics, 1995. 18(9): p. 871-3.
    7. Kurtz, S., et al., 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): p. 780-5.
    8. Ramos, N., et al., Prior Staphylococcus Aureus Nasal Colonization: A Risk Factor for Surgical Site Infections Following Decolonization. J Am Acad Orthop Surg, 2016. 24(12): p. 880-885.
    9. Mainous, A.G., 3rd, et al., Nasal carriage of Staphylococcus aureus and methicillin-resistant S aureus in the United States, 2001-2002. Ann Fam Med, 2006. 4(2): p. 132-7.
    10. Wertheim, H.F., et al., The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis, 2005. 5(12): p. 751-62.
    11. Chen, A.F., C.B. Wessel, and N. Rao, Staphylococcus aureus screening and decolonization in orthopaedic surgery and reduction of surgical site infections. Clin Orthop Relat Res, 2013. 471(7): p. 2383-99.
    12. Courville, X.F., et al., 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): p. 152-9.
    13. Torres, E.G., et al., Is Preoperative Nasal Povidone-Iodine as Efficient and Cost-Effective as Standard Methicillin-Resistant Staphylococcus aureus Screening Protocol in Total Joint Arthroplasty? J Arthroplasty, 2016. 31(1): p. 215-8.
    14. Schweizer, M.L., et al., Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA, 2015. 313(21): p. 2162-71.
    15. Edmiston, C.E., et al., Preadmission Application of 2% Chlorhexidine Gluconate (CHG): Enhancing Patient Compliance While Maximizing Skin Surface Concentrations. Infect Control Hosp Epidemiol, 2016. 37(3): p. 254-9.
    16. Abbas, S. and S. Sastry, Chlorhexidine: Patient Bathing and Infection Prevention. Curr Infect Dis Rep, 2016. 18(8): p. 25.
    17. Kapadia, B.H., R.K. Elmallah, and M.A. Mont, A Randomized, Clinical Trial of Preadmission Chlorhexidine Skin Preparation for Lower Extremity Total Joint Arthroplasty. J Arthroplasty, 2016. 31(12): p. 2856-2861.
    18. Johnson, A.J., et al., Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty. J Arthroplasty, 2010. 25(6 Suppl): p. 98-102.
    19. Kapadia, B.H., et al., Pre-admission cutaneous chlorhexidine preparation reduces surgical site infections in total hip arthroplasty. J Arthroplasty, 2013. 28(3): p. 490-3.
    20. Chlebicki, M.P., et al., Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control, 2013. 41(2): p. 167-73.
    21. Burke, J.F., The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery, 1961. 50: p. 161-8.
    22. Oishi, C.S., W.V. Carrion, and F.T. Hoaglund, Use of parenteral prophylactic antibiotics in clean orthopaedic surgery. A review of the literature. Clin Orthop Relat Res, 1993(296): p. 249-55.
    23. Norton, T.D., et al., Orthopedic surgical site infections: analysis of causative bacteria and implications for antibiotic stewardship. Am J Orthop (Belle Mead NJ), 2014. 43(5): p. E89-92.
    24. Bosco, J.A., et al., Expanded Gram-Negative Antimicrobial Prophylaxis Reduces Surgical Site Infections in Hip Arthroplasty. J Arthroplasty, 2016. 31(3): p. 616-21.
    25. Sewick, A., et al., Does dual antibiotic prophylaxis better prevent surgical site infections in total joint arthroplasty? Clin Orthop Relat Res, 2012. 470(10): p. 2702-7.
    26. Gans, I., et al., Adjunctive vancomycin powder in pediatric spine surgery is safe. Spine (Phila Pa 1976), 2013. 38(19): p. 1703-7.
    27. Godil, S.S., et al., Comparative effectiveness and cost-benefit analysis of local application of vancomycin powder in posterior spinal fusion for spine trauma: clinical article. J Neurosurg Spine, 2013. 19(3): p. 331-5.
    28. Molinari, R.W., O.A. Khera, and W.J. Molinari, 3rd, Prophylactic intraoperative powdered vancomycin and postoperative deep spinal wound infection: 1,512 consecutive surgical cases over a 6-year period. Eur Spine J, 2012. 21 Suppl 4: p. S476-82.
    29. O’Neill, K.R., et al., Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J, 2011. 11(7): p. 641-6.
    30. Schroeder, J.E., et al., The use of local vancomycin powder in degenerative spine surgery. Eur Spine J, 2016. 25(4): p. 1029-33.
    31. Wukich, D.K., et al., Topically Applied Vancomycin Powder Reduces the Rate of Surgical Site Infection in Diabetic Patients Undergoing Foot and Ankle Surgery. Foot Ankle Int, 2015. 36(9): p. 1017-24.
    32. Field, F.K. and M.D. Kerstein, Overview of wound healing in a moist environment. Am J Surg, 1994. 167(1A): p. 2S-6S.
    33. Vogt, P.M., et al., Dry, moist, and wet skin wound repair. Ann Plast Surg, 1995. 34(5): p. 493-9; discussion 499-500.
    34. Winter, G.D., Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature, 1962. 193: p. 293-4.
    35. Vasconcelos, A. and A. Cavaco-Paulo, Wound dressings for a proteolytic-rich environment. Appl Microbiol Biotechnol, 2011. 90(2): p. 445-60.
    36. Grosso, M.J., et al., Silver-Impregnated Occlusive Dressing Reduces Rates of Acute Periprosthetic Joint Infection After Total Joint Arthroplasty. J Arthroplasty, 2016.
    37. Cai, J., et al., Aquacel surgical dressing reduces the rate of acute PJI following total joint arthroplasty: a case-control study. J Arthroplasty, 2014. 29(6): p. 1098-100.
    38. Dobbelaere, A., et al., Comparative study of innovative postoperative wound dressings after total knee arthroplasty. Acta Orthop Belg, 2015. 81(3): p. 454-61.
    39. Ravnskog, F.A., B. Espehaug, and K. Indrekvam, Randomised clinical trial comparing Hydrofiber and alginate dressings post-hip replacement. J Wound Care, 2011. 20(3): p. 136-42.
    40. Ravenscroft, M.J., J. Harker, and K.A. Buch, A prospective, randomised, controlled trial comparing wound dressings used in hip and knee surgery: Aquacel and Tegaderm versus Cutiplast. Ann R Coll Surg Engl, 2006. 88(1): p. 18-22.
    41. Hopper, G.P., et al., Enhancing patient recovery following lower limb arthroplasty with a modern wound dressing: a prospective, comparative audit. J Wound Care, 2012. 21(4): p. 200-3.
    42. Chowdhry, M. and A.F. Chen, Wound dressings for primary and revision total joint arthroplasty. Ann Transl Med, 2015. 3(18): p. 268.
    43. Williams, C., An investigation of the benefits of Aquacel Hydrofibre wound dressing. Br J Nurs, 1999. 8(10): p. 676-7, 680.
    44. Dumville, J.C., et al., Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev, 2014(9): p. CD003091.
    45. Ubbink, D.T., et al., Occlusive vs gauze dressings for local wound care in surgical patients: a randomized clinical trial. Arch Surg, 2008. 143(10): p. 950-5.