Screening and decolonization of MRSA among joint arthroplasty patients: efficacy, cost-effectiveness and durability

Staphylococcus aureus (S. aureus) is the most common organism responsible for orthopaedic surgical site infections (SSIs) after elective joint arthroplasty. Patients who are carriers for methicillin resistant S. aureus (MRSA) have a higher likelihood of having invasive MRSA infections[1]. Some reports have suggested that screening and decolonization of all patients having elective joint arthroplasty will decrease the incidence of postoperative infections[2]. They believe that a prescreening program (nasal swab using polymerase chain reaction-based testing), followed by an appropriate eradication using a 5to 14-d course of nasal mucopirocin (2% nasal ointment) will lower the rate of SSIs[3]. Although some have advocated screening and decolonization[3,4], it is unclear whether these efforts reduce SSIs[1]. In other words, while some institutions and surgeons have implemented universal screening and decolonization on their patients undergoing elective arthroplasty, others remain unconvinced about the efficacy of this process[5]. The purpose of this article is to revise the literature with the aim of answering the following three questions: 1) Is screening and decolonization of MRSA effective in reducing the incidence of postoperative infection after elective joint arthroplasty? 2) Is decolonization cost-effective? 3) What is the durability of decolonization? Objective: To review the literature with the aim of answering the following three questions: 1) Is screening and decolonization effective in reducing the rate of infection after elective joint arthroplasty? 2) Is screening and decolonization cost-effective? 3) What is the durability of decolonization? Methods: The search engines were MedLine (PubMed), Google Scholar and the Cochrane Library. The keywords used were: preoperative MRSA screening. Seven thousand nine hundred and forty eight articles were found until 30 September 2014 (seven thousand eight hundred and fifty in Google Scholar, ninety-seven in MedLine and one in the Cochrane Library). Of those, only eighteen were selected and reviewed because they were strictly focused on the question of this article. Results: The types of studies reported have a low level of evidence. Most of them are prospective case series, although some of them are systematic reviews of level III studies. There is a tendency toward fewer MRSA infections after elective joint arthroplasty. Decolonization has shown to be strongly cost-effective with 33% of postoperative arthroplasty patients tests positive for Staphylococcus aureus colonization at 3 to 30 months after surgery. Conclusions: There is a tendency toward fewer MRSA infections after total joint arthroplasty when screening and decolonization is used. Decolonization is strongly cost-effective procedure with 33% of patients tests positive for MRSA 3 to 30 months after surgery. Larger, randomized, controlled studies are needed to confirm the apparent efficacy of decolonization. Journal of Acute Disease (2014)218-220