Title: Mitigation and Education
Liaisons: Vinay K Aggarwal MD, Eric H Tischler BA
Leaders: Charles Lautenbach MD, Gerald R Williams Jr MD
Delegates: Joseph A Abboud MD, Mark Altena MD, Thomas Bradbury MD, Jason Calhoun MD, FACS, Douglas Dennis MD, Daniel J Del Gaizo MD, Lluís Font-Vizcarra MD, Kaisa Huotari MD, Stephen Kates MD, Kyung-Hoi Koo PhD, Tad M Mabry MD, Calin Stefan Moucha MD, Julio Cesar Palacio MD, Trisha Nicole Peel MBBS, Rudolf W.Poolman MD, PhD, William J Robb III MD, Ralph Salvagno MD, Thorsten Seyler MD, Gabor Skaliczki MD, Edward M Vasarhelyi MD, William Charles Watters III, MD
Vol 1, Num S1, September 2014
Question 1A: What are the significant risk factors for development of surgical site infection (SSI) or periprosthetic joint infection (PJI) after elective total joint arthroplasty (TJA)?
Consensus: Active infection of the arthritic joint (septic arthritis), presence of septicemia, and/or presence of active local cutaneous, subcutaneous, or deep tissue infection are all significant risk factors predisposing patients to SSI or PJI and are contraindication to undertaking elective TJA.
Delegate Vote: Agree: 99%, Disagree: 0%, Abstain: 1% (Strong Consensus)
Question 1B: What are the potential risk factors for development of SSI or PJI after elective TJA?
Consensus: The risk factors for SSI or PJI include history of previous surgery, poorly controlled diabetes mellitus (glucose> 200 mg/L or HbA1C>7%), malnutrition, morbid obesity (BMI>40 Kg/m2), active liver disease, chronic renal disease, excessive smoking (>one pack per day), excessive alcohol consumption (>40 units per week), intravenous drug abuse, recent hospitalization, extended stay in a rehabilitation facility, male gender, diagnosis of post-traumatic arthritis, inflammatory arthropathy, prior surgical procedure in the affected joint, and severe immunodeficiency.
Delegate Vote: Agree: 94%, Disagree: 4%, Abstain: 2% (Strong Consensus)
Question 2: What is the role of oral hygiene for patients undergoing an elective arthroplasty?
Consensus: All patients undergoing elective arthroplasty should be screened for evidence of active infection. This may be performed by administration of a questionnaire or dental examination.
Delegate Vote: Agree: 80%, Disagree: 18%, Abstain: 2% (Strong Consensus)
Question 3A: What should the process be for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) screening?
Consensus: While this workgroup does NOT recommend universal screening and decolonization of all patients undergoing joint arthroplasty, it accepts that preoperative screening for Staphylococcus aureus (MSSA and MRSA) and decolonization decreases the rate of SSI and the incidence of staphylococcal and nonstaphylococcal infections.
Delegate Vote: Agree: 85%, Disagree: 11%, Abstain: 4% (Strong Consensus)
Question 3B: What should the treatment regimen be for MRSA and methicillin-sensitive MSSA decolonization?
Consensus: Short-term nasal application of mupirocin is the most accepted current method of decolonization for MRSA and/or MSSA.
Delegate Vote: Agree: 80%, Disagree: 11%, Abstain: 9% (Strong Consensus)
Question 4: Should healthcare workers be screened for MRSA and MSSA?
Consensus: No. Routine MRSA and MSSA screening is not warranted for healthcare workers. MRSA/MSSA screening should be reserved for workers with symptoms associated with bacterial infections.
Delegate Vote: Agree: 82%, Disagree: 15%, Abstain: 3% (Strong Consensus)
Question 5: What is the role of routine urine screening in patients undergoing an elective arthroplasty?
Consensus: Routine urine screening is NOT warranted for patients undergoing elective arthroplasty. Urine screening prior to elective arthroplasty should be reserved for patients with a present history or symptoms of a urinary tract infection (UTI).
Delegate Vote: Agree: 74%, Disagree: 24%, Abstain: 2% (Strong Consensus)
Question 6: Should disease-modifying agents be stopped prior to elective TJA?
Consensus: Yes. Disease-modifying agents should be stopped prior to elective TJA. The timing of drug discontinuation should be based on the specific medication and the individual patient. The cessation of immunosuppressant medications should be performed in consultation and under the direction of the treating physician.
Delegate Vote: Agree: 92%, Disagree: 5%, Abstain: 3%(Strong Consensus)
Question 7: In patients with prior septic arthritis what strategies should be undertaken to minimize the risk of subsequent PJI?
Consensus: ALL patients with prior septic arthritis should undergo evaluation by serology and aspiration of the joint whenever possible, prior to arthroplasty.
Delegate Vote: Agree: 84%, Disagree: 14%, Abstain: 2% (Strong Consensus)
Consensus: While the optimal timing for performing elective arthroplasty in a patient with prior septic arthroplasty needs further research, surgeons should ensure that no evidence of active infection exists by taking intraoperative cultures.
Delegate Vote: Agree: 85%, Disagree: 14%, Abstain: 1% (Strong Consensus)
Consensus: During arthroplasty, if cement is utilized, antibiotics should be added.
Delegate Vote: Agree: 90%, Disagree: 5%, Abstain: 5% (Strong Consensus)
Consensus: If intraoperative cultures are found to be positive, extended intravenous antibiotics should be appropriately administered with input from infectious disease specialists.
Delegate Vote: Agree: 93%, Disagree: 5%, Abstain: 2% (Strong Consensus)