THIS WEEK'S ARTICLES
Best Practices in Preventing Joint Infections
Precise execution of a multimodal strategy with the right patients is key.
In a recent study that reviewed the latest strategies used to prevent prosthetic joint infection (PJI) in hip and knee replacement patients, the authors say glycemic control, improved nutritional status, weight optimization and smoking cessation are important factors to address before surgery.
The study, published in the journal Current Reviews in Musculoskeletal Medicine, cites research that notes diabetic patients with HbA1c levels of at least 7.5 mg/dl have a significantly higher risk of deep joint infection. Using HbA1c thresholds as the ideal marker for glycemic control, however, might not be best practice, as there is growing evidence that measuring serum fructosamine is a superior predictor of PJI risks. Although studies have shown that malnourished patients are at a higher risk for surgical site infections, research is not clear on the impact delaying procedures until nutritional optimization takes place has on positive outcomes.
Research has shown that preoperative bariatric surgery for obese patients is a potential intervention that could reduce PJI risks during joint replacements, according to the study. The optimal timing between weight-loss surgery and the joint replacement procedure hasn't been determined, however. The study also cites a 2019 meta-analysis that shows smokers are at a significantly higher risk of PJI and wound complications overall.
Infection prevention bundles can also provide positive synergistic effects of multiple interventions, note the study's authors. They say implementation of a bundle that included staff education, nasal decolonization using mupirocin and reduced OR traffic during procedures, among other strategies, showed a drop in infection rates from 1.4% to 0.37% among joint replacement patients.
PJI is an uncommon but devastating result of hip and knee arthroplasty. Although the study's authors concede the lack of a silver bullet to prevent PJIs, they say what is clear is that the perioperative strategies that rise to the top as they evolve will include patient optimization, a multimodal approach to infection prevention and an attention to detail while executing both.
Drawing a Bead on Infection Prevention
Administer antibiotics where they’re needed most after joint replacements.
Coating surgical implants with antibiotic beads the size of grains of salt helps to prevents surgical site infections three to six weeks after joint replacement surgery, a period during which infections are most likely to occur.
Terry Clyburn, MD, an orthopedic surgeon at Houston Methodist Hospital, worked with colleagues from nearby Rice University and UT Health to develop microspheres, which feature several layers of antibiotics that completely dissolve over time to gradually deliver the medications directly at the surgical site.
Dr. Clyburn and his team tested the efficacy of the microspheres by contaminating one of two metal implants with Staphylococcus aureus bacteria before both implants were inserted into animal models. The animal model that received the implant covered with microspheres did not develop an infection.
"There is a risk of infection with any surgery, but infections after a joint replacement surgery are harder to treat," says Dr. Clyburn. "The metal implants are not connected to the body's bloodstream, so the white blood cells sent to fight the infection cannot reach the implant and kill the bacteria."
Joint replacement surgeons administer a course of intravenous antibiotics before and after surgery, but that practice isn't always effective. Approximately 10,000 of the more than one million patients who undergo joint replacement surgery each year suffer post-op infections. Coating implants with antibiotic microspheres prevents bacteria from forming within the joint and causing an infection.
"If an infection does develop after a joint replacement surgery, many patients may require surgery to thoroughly clean around the implant or even replace it," says Dr. Clyburn. "That's why I worked to develop these microspheres — to help protect my patients and reduce their risk for major complications after surgery."
Reducing Surgical Site Infections in Total Joints
Four ways your care team can combat SSIs.
Surgical site infections (SSIs) are always top of mind for any OR team as they implement procedures and employ strategies for patient safety. Whether you’re doing total joint procedures today or plan to add them in the future, it’s important for your staff to have the tools and knowledge available to them to help prevent, diagnose and treat surgical site infections.
SSIs are expected to increase by an alarming 198% by 2023 for knee and hip replacements, and the cost to the healthcare system for knee and shoulder infections is projected to reach $1.62 billion.1 Today, surgical site infections contribute to the most common reasons that knee and hip surgeries require a second visit to the OR for revisions.2
Clearly, a focus on SSIs and ways to reduce them is of critical importance in total joint procedures and it's equally critical that your staff is armed with the best resources to help reduce SSIs. Here are four ways to help reduce SSIs.
Begin with the skin. About 80% of skin flora occurs on the outer skin layers.2 In fact, one square centimeter of skin can host as many as 10 million aerobic bacteria, a leading cause of healthcare-acquired infections.1 A single-use skin prep applicator can help reduce skin flora by moving the clinician’s hand away from the patient’s skin for a more aseptic technique (this does not apply to the swabstick format). A proprietary tinting process also allows the clinician to see the prepped area more clearly.
Tables take cover. Are you covering your tables and stands? The Association of periOperative Registered Nurses (AORN) guidelines state that the sterile field – including tables – should be covered if not being used immediately.3 You can help significantly reduce the risk for contamination by covering even just portions of the sterile field that are not in active use.3
The American Journal of Infection Control recently published a study stating that covering sterile tables reduced bacterial contaminations at four and eight hours. The study also suggested that covered tables reduce the amount of bioburden that can collect on unused instruments.4
Beware the colonies. Research suggests that the risk of SSI increases up to nine times due to nasal colonization of Staphylococcus aureus, presenting a big challenge in surgical settings.5 Pre-op testing for MRSA is not always included at surgical facilities, but some proactive clinicians have modified their pre-op protocol to treat every surgical patient with a nasal iodine-saturated swab, often with favorable results.6 Nasal swab tests allow clinicians to detect and identify MRSA for better prevention and control. Scalable instrument models fit into a wide variety of testing environments, including surgery centers that are usually challenged for space.
Dress for success. Not all orthopedic surgical gowns are created equal. High-quality surgical gowns should meet or exceed testing standards of the American National Standards Institute and the Association for the Advancement of Medical Instrumentation, and they should be certified to meet AAMI level 3 standards for all critical zones. When selecting a gown, be sure to choose one that’s resistant to tears, punctures, strikethrough and fiber strains — and also is comfortable for your staff to use every day.
Note: For more information on SSI prevention and products that help reduce infections in total joints, please go to visit the McKesson orthopedics webpage.
1. Kurtz SM, Lau E,Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012; 27(8) (suppl):61-5.e1.
2. Readmission Rates, Causes, and Costs Following Total Joint Arthroplasty in US Medicare Population, W. Murphy, P. Lane, B. Lin, T. Cheng, D. Terry, S. Murphy; Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010; 468(1):45-51.
3. AORN Guidelines for Perioperative Practice, 2018 Edition
4. Markel, et al. Covering the instrument table decreases bioburden: An evaluation of environmental quality indicators, American Journal of Infection Control, 2018
5. Price CS, Williams A, Philips G, Dayton M, Smith W, Morgan S. Staphylococcus aureus nasal colonization in preoperative orthopaedic outpatients. Clin Orthop Relat Res. 2008; 466(11):2842-2847.
6. Outpatient Surgery Magazine, 2018
7. Melissa S. Schmidt, MSN, RN, CNL, CPAN, CAPA, PACU.; VandenBergh MF, Yzerman EP, van Belkum A, Boelens HA, Sijmons M, Verbrugh HA. Follow-up of Staphylococcus aureus nasal carriage after 8 years: redefining the persistent carrier state. J Clin Microbiol.1999; 37:3133-3140.
Improving the Care of High-Risk Patients
Patient screenings and targeted strategies can prevent post-op infections.
All patients who undergo total joint arthroplasties (TJA) are at risk for complications and post-op infections. However, medical comorbidities and lifestyle factors can significantly increase their risks of suffering surgical site infections (SSIs) and periprosthetic joint infections (PJIs), and these should be addressed well before the day of surgery.
That's according to the authors of a recent study published in the journal Arthroplasty, which identifies factors that predispose patients to SSIs and PJIs: colonization with methicillin-sensitive Staphylococcus aureus or methicillin-resistant Staphylococcus aureus; rheumatoid arthritis; cardiovascular and renal diseases; obesity; diabetes mellitus; hyperglycemia; anemia; malnutrition; tobacco use; alcohol consumption; depression; and anxiety.
The study details interventional techniques for each identified risk factor, some of which are more common in patients older than 64 years, note the authors. All of these risk factors are modifiable and should be addressed to optimize patients for surgery, they say.
The study's authors highlight the need for preoperative patient screening two to six weeks before surgery to identify risk factors for infection, along with transparent communication among multidisciplinary care teams to improve patient outcomes. Patients with multiple risk factors for infection require a dynamic treatment plan that includes more comprehensive medical treatment and follow-up care to prevent the risk factors from recurring.
These interventions will become vitally important as the demand for TJA continues to climb. Infection rates will increase accordingly if high-risk patients aren’t identified, educated and treated preoperatively. "Implementing preoperative infection prevention protocols with widespread diligence and awareness can improve surgical outcomes and increase patient satisfaction," the authors write.
How One Orthopedic Surgeon Keeps Infections at Bay
Fundamental practices eliminate SSIs in his joint replacement patients.
The last thing surgeons — or their patients — want to deal with after a successful total joint replacement is a deep wound infection. Here’s how Ronald Singer, MD, an orthopedic surgeon affiliated with OrthoCarolina in Charlotte, tackles the issue head on to ensure his patients leave his facility healthy, happy and infection-free:
- Identifying high-risk patients. Dr. Singer says joint replacement patients are at high risk of infection if they have multiple comorbidities, including uncontrolled diabetes, obesity, hypertension or a compromised immune system. He suggests mitigating the following risk factors in the weeks leading up to surgery: smokers should kick the habit at least six weeks out; patients with a body-mass index (BMI) over 38 should lose weight until their BMI is at an acceptable threshold (< 35, for example); and diabetics should be treated with medication, diet and exercise until their A1C is under seven.
- Nasal decolonization. About 80% of wound infections are traced to patients’ nasal flora, so treating their nares before surgery is a proven way to reduce infection risks, points out Dr. Singer. In the outpatient setting, he says, it’s often more practical to assume that all patients are carriers and treat their nares leading up to and on the day of surgery with povidone-iodine or an alcohol-based antiseptic, rather than screen and treat MRSA carriers with a course of the nasal antibiotic mupirocin for five days.
- Wound care. Negative-pressure dressings have been critical to Dr. Singer’s infection prevention efforts. The dressings are attached by a plastic tube to a small pump, which creates a negative pressure at the wound to prevent fluid from collecting in surrounding tissue and improves wound healing.
- Limiting blood loss. Dr. Singer performs tourniquet-free surgery, which lowers the risk of hematomas forming in tissue around joints or hemarthrosis occurring in the joint space, both of which increase the risk of infection.
- Maintaining normothermia. His patients are actively warmed with a conductive warming device before, during and after procedures, a practice that has been shown to reduce the risk of post-op infection.
Dr. Singer is quick to point out that his efforts are part of a multidisciplinary team approach. "Preventing infections in joint replacement patients requires dedicating valuable time and allocating numerous resources," he says, "but the stakes are too high and payoff too great to ignore its importance."