Ana I. Ribau, MD; Jamie E. Collins, PhD; Antonia F. Chen, MD, MBA; Ricardo J. Sousa, MD, PhD
The Journal of Arthroplasty, Volume 36, Issue 2, 2021.
DOI: 10.1016/j.arth.2020.08.014
Summary by Serge Tzeuton, BS
Staphylococcus Aureus is among the most common pathogens known to cause orthopedic infections. Staphylococcus aureus is also a common pathogen for which many patients are carriers. Research has suggested that being a carrier of S. aureus increases the likelihood of developing post-operative infections. Given so many patients are S. aureus carriers, S. aureus screening and decolonization techniques have been developed to try to reduce the incidence of post-operative infections. However, research has demonstrated mixed efficacy of these interventions. This systematic review sought to investigate how efficacious and how cost-effective these efforts are in reducing orthopedic surgical site infection, particularly in elective total joint arthroplasty.
Ribau et. al conducted a retrospective systematic review and meta-analysis of the PubMed, Ovid MEDLINE, and Cochrane databases on January 1, 2020 to assess whether the current literature suggests that S. aureus screening and decolonization reduces likelihood of post-operative orthopedic infection. The search identified 1260 articles that were potentially relevant, and ultimately 32 papers were included in the study.
The review found that overall S. aureus carriage rate ranged from 15% to 30%. The relative risk (RR) of developing any infection after orthopedic surgery without S. aureus nares decolonization was 1.85 +/- 0.28, and the RR for developing S. aureus infection, in particular, was 1.62 +/- 0.29. In regards to TJA specifically, the RR of developing any infection without S. aureus nares decolonization was 1.60 +/- 0.45.
The RR of getting post-operative orthopedic infection without nares AND whole-body decolonization was 1.71 +/- 0.16, and the RR for specifically developing S. aureus infection was 2.79 +/- 0.45. The RR of developing any infection after TJA without nares and whole-body decolonization was 1.70 +/- 0.17.
When assessing whether treated carriers were similar to non-carriers of S. aureus, the RR of developing any infection in treated carriers was not different from that of non-carriers; however the RR of specifically developing S. aureus infection in treated carriers was 4.64 +/- 0.13 compared to non-carriers.
Several papers showed that pre-operative decolonization for S. aureus was cost-effective. The literature suggested that screening and decolonization of S. aureus would result in a large annual cost savings, maybe as high $1.26 million annually in Alberta alone.
The review found that preoperative S. aureus decolonization lowered the risk of infection after orthopedic surgery for treated and non-treated carriers of S. aureus. All potential decolonization strategies are shown to decrease costs for the US health system. The meta-analysis was limited by the relatively few prospective studies available (five) and large variations in methodologies, which prevented the authors from conducting a meta-analysis comparing noncarriers to carriers and to nontreated carriers in the TJA group.