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.
Kevin Chen, MA; Ameer Elbuluk, BA; Samir Nayyar, MD; Duke Hasson, MD; Ran Schwarzkopf, MD MSc; and Jonathan Vidgorchik, MD
The authors have no disclosures relevant to this article.
Infection remains one of the most common and costly complications following total joint arthroplasty (TJA).  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  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. 
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.
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  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. 
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  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  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). 
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.
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.  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  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  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). 
However, in a meta-analysis by Chlebicki et al,  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. 
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,  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  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  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: :
- 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  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.
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  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  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. 
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). 
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). 
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.
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  and Cai et al  have demonstrated strong evidence supporting the use hydrofibre dressings when compared with other types of dressings.
Grosso et al  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  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.  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,  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.
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.
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.
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