Decreased Hospital Costs and Surgical Site Infection Incidence With a Universal Decolonization Protocol in Primary Total Joint Arthroplasty.
Staphylococcus aureus colonization has been identified as a key modifiable risk factor in the reduction of surgical site infections (SSI) related to elective total joint arthroplasty (TJA). We investigated the incidence of SSIs and cost-effectiveness of a universal decolonization protocol without screening consisting of nasal mupirocin and chlorhexidine before elective TJA compared to a program in which all subjects were screened for S aureus and selectively treated if positive.



We reviewed 4186 primary TJAs from March 2011 through July 2015. Patients were divided into 2 cohorts based on the decolonization regimen used. Before May 2013, 1981 TJA patients were treated under a "screen and treat" program while the subsequent 2205 patients were treated under the universal protocol. We excluded the 3 months around the transition to control for treatment bias. Outcomes of interest included SSI and total hospital costs.



With a universal decolonization protocol, there was a significant decrease in both the overall SSI rate (5 vs 15 cases; 0.2% vs 0.8%; P = .013) and SSIs caused by S aureus organisms (2 vs 10; 0.09% vs 0.5%; P = .01). A cost analysis accounting for the cost to administer the universal regimen demonstrated an actual savings of $717,205.59. TJA complicated by SSI costs 4.6× more to treat than that of an uncomplicated primary TJA.



Our universal decolonization paradigm for elective TJA is effective in reducing the overall rate of SSIs and promoting economic gains for the health system related to the downstream savings accrued from limiting future reoperations and hospitalizations.
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Jeffrey B
JB
Stambough
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Denis
D
Nam
Division of Infectious Diseases, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri.
David K
DK
Warren
Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.
James A
JA
Keeney
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri.
John C
JC
Clohisy
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Robert L
RL
Barrack
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Ryan M
RM
Nunley
D000281:Administration, Intranasal; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000191:economics; D001178:Arthroplasty / Q000009:adverse effects; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000191:economics; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects / Q000191:economics; D002710:Chlorhexidine / Q000008:administration & dosage* / Q000191:economics; D003362:Cost-Benefit Analysis; D017558:Elective Surgical Procedures / Q000009:adverse effects; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008923:Missouri / Q000453:epidemiology; D016712:Mupirocin / Q000008:administration & dosage* / Q000191:economics; D016459:Prosthesis-Related Infections / Q000191:economics / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D012189:Retrospective Studies; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000517:prevention & control; D013211:Staphylococcus aureus / Q000302:isolation & purification; D013530:Surgical Wound Infection / Q000191:economics / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*
D000900:Anti-Bacterial Agents; D016712:Mupirocin; D002710:Chlorhexidine
Staphylococcus aureus; cost effectiveness; decolonization; prosthetic joint infection; surgical site infection; total joint arthroplasty