What is the most cost‐effective strategy for nasal screening and Staphylococcus aureus decolonization in patients undergoing total hip arthroplasty?

Abstract

Background To reduce periprosthetic joint infection after total hip arthroplasty (THA), several nasal screening and decolonization strategies for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) have been performed. These include universal decolonization (UD; i.e., no screening and decolonization for all patients), universal screening and target decolonization (US; i.e., screening for all patients and decolonization for bacterial positive patients), and target screening and decolonization (TS; i.e., screening and decolonization for high-risk populations only). Although TS is the most cost-effective strategy, useful risk factors must be identified. The purpose of this study was to evaluate the presence of predictive factors that enable the TS strategy to be successfully implemented and to compare the costs of each strategy. Methods A total of 1654 patients scheduled for primary or revision THA (1464 female, 190 male; mean age 64 years) were screened prior to surgery for bacterial colonization of the nasal mucosa. Risk factors for positive MRSA and S. aureus (including both MRSA and MSSA) tests were analyzed according to the following parameters: sex, age ≥ 80 years, body mass index ≥ 30 kg/m2, antibiotic use within 3 years, corticosteroid use, serum albumin < 3.5 g/dL, glomerular filtration rate < 50 mL/min, presence of brain, thyroid, cardiac, or pulmonary disease, diabetes, asthma, smoking status, and whether revision surgery was performed. The average cost of each strategy was calculated. Results In total, 29 patients (1.8 %) tested positive for MRSA and 445 (26.9 %) tested positive for S. aureus. No parameters were identified as independent risk factors for MRSA and only female sex was identified as a risk factor for S. aureus (p = 0.003; odds ratio: 1.790; 95 % confidence interval: 1.210–2.640). The average cost of each strategy was 1928.3 yen for UD, 717.6 yen for US, and 717.6 yen for TS (for eradicating MRSA), and 1928.3 yen for UD, 1201.6 yen for US, and 1160.4 yen for TS (for eradicating S. aureus). Conclusions No useful predictive parameters for implementing the TS strategy were identified. Based on cost implications, US is the most cost-effective strategy for THA patients.

Diagnóstico e prevenção de infecções articulares periprotéticas por Staphylococcus aureus após fratura de quadril: Revisão sistemática de literatura

“…Em todos os casos, foram utilizados no protocolo de descolonização mupirocina tópica (pomada) nas narinas com aplicação de 2 a 3 vezes ao dia durante 5 dias, associado a banhos diários com clorexidina a 2-4%. 21,[25][26][27][28][29][30][31][32][33] Destes, apenas três ressaltaram a efetividade da descolonização para redução de IAP, sendo que em um dos estudos houve redução apenas da IAP precoce causada por S. aureus, não reduzindo a IAP global. 27 Nos outros dois estudos, houve redução da IAP global 32,33 e ainda um dos estudos mostrou redução de infecções do sítio cirúrgico nos pacientes com descolonização pré-operatória.…”

“…Thus, it would not be possible to identify useful predictive parameters for nasal screening, thus requiring universal decolonization in patients undergoing the surgical procedure. 25 Ten studies addressed preoperative decolonization procedures as a way to prevent the occurrence of PJI. In all cases, topical mupirocin (ointment) was used in the nostrils in the decolonization protocol, applied 2 to 3 times a day for 5 days, associated with daily baths with 2 to 4% chlorhexidine.…”

“…In all cases, topical mupirocin (ointment) was used in the nostrils in the decolonization protocol, applied 2 to 3 times a day for 5 days, associated with daily baths with 2 to 4% chlorhexidine. 21,[25][26][27][28][29][30][31][32][33] Of these, only three emphasized the effectiveness of decolonization to reduce PJI, and in one of the studies there was a reduction only in early PJI caused by S. aureus, not reducing global PJI. 27 In the other two studies, there was a reduction in overall PJI 32,33 and one of the studies also showed a reduction in surgical site infections in patients with preoperative decolonization.…”

“…33 In both cases, useful predictive parameters for the implementation of the screening strategy were not identified, considering that universal decolonization would be effective and appropriate in cases of patients undergoing hip arthroplasties. 25,29,33 Among the selected studies, antibiotic prophylaxis was also addressed, discussing aspects related to the type of drug to be used, as well as variables considered for initiation and discontinuation. In Turkey, it was observed that most surgeons (56.8%) use antibiotic prophylaxis for a longer period than proposed in the guidelines (> 24 hours), glycemic assessment before surgery was performed by 94% of the sample, and decolonization for MRSA was performed by 33.3% of study participants.…”

“…Desta forma, não seria possível a identificação de parâmetros preditivos úteis para a triagem nasal, exigindo assim a descolonização universal nos pacientes submetidos ao procedimento cirúrgico. 25 Dez estudos abordaram procedimentos de descolonização pré-operatória como forma de prevenção da ocorrência de IAP. Em todos os casos, foram utilizados no protocolo de descolonização mupirocina tópica (pomada) nas narinas com aplicação de 2 a 3 vezes ao dia durante 5 dias, associado a banhos diários com clorexidina a 2-4%.…”