Introduction: Surgical site infections (SSIs) are a serious complication in orthopaedic surgery which may lead to permanent disability and even mortality. Nasal carriage of Staphylococcus aureus (S.aureus) is associated with an increased risk for development of SSI in orthopaedic surgery. The risk for SSI can be reduced by perioperative decolonization of S. aureus carriage. This study was performed to determine whether hospitals and private clinics in the Netherlands screen and subsequently treat patients undergoing orthopaedic surgery on S. aureus nasal carriage.

Method: A survey about SSI reduction, screening and S. aureus eradication in patients eligible for knee or hip replacement was sent to the Dutch Orthopaedic Association (DOA).

Results:  The response to the survey was low; only 50 of the 1350 members of the DAO (3.6%) responded. One quarter of the responders (24%) do not screen or treat patients for S. aureus nose carriage for patients undergoing knee or hip replacement.  Twenty percent of responders use prophylactic decolonization but do not screen for S. aureus carriage and indicate that screening before surgery is “not cost-effective”.

Conclusions: Although the response on the survey about decolonisation of S. aureus nose carriage at orthopaedic surgery was low (3.6%), it seems clear that there is no concrete policy in hospitals and private clinics in the Netherlands about screening and treating patients undergoing a knee or hip replacement.

Author: G.M.M Lelieveld-Vroom, infection prevention controller, Alrijne hospital, Department infection prevention­


Prevention of surgical site infections is a important component of nosocomial infection control and a major priority in orthopaedic surgery. Surgical wound contamination must be prevented to avoid patient colonisation by microorganisms during surgery. SSI can double the length of hospitalization and thereby increases the costs of health care1,2. Additional costs attributed to SSI range from 1.000 euro (superficially SSI) up to 20.000 euro (deep SSI)3. More importantly infections may lead to severe morbidity, including  loss of the implant.

Staphylococcus aureus nasal carriage is associated with an increased risk for developing a health care-related infection with this micro-organism4. The risk of infection in nasal carriers is estimated to be two to twelve times higher than in those who are not colonised with S.aureus5. Nasal carriage is a well-defined risk factor for subsequent infections, 7,5 percent versus 3-5 percent, considering all hospital admissions5. The number of surgical-site infections acquired in the hospital can be reduced by decolonizing nasal carriers of S. aureus pre-operatively 6,7,8,9

The aim of this study was to examine to which level the preventive strategy of nasal decolonization is applied to patients prior to orthopaedic surgery in the Netherlands.

A survey with questions concerning S. aureus screening and/or prophylactic decolonization of patients prior to a total knee or hip replacement was sent to the DOA. The DOA was asked to distribute a link to the survey made in Survey Monkey10 to its 1350 members. The survey consisted of closed and open questions, included 13 questions about SSI reduction, screening and eradication of S. aureus carriage prior to a total knee or a hip replacement. It was sent to the DOA in December 2015, with  a reminder set in February 2016.

The response rate to the survey was very low (3.6%), despite sending out a second reminder. Of the responders 35 (70%) were orthopaedic surgeons, 2 (4%) were resident orthopaedic surgeons, and 5 (10%) an orthopaedic physician assistants. Eight respondents (16%) gave no answer to this question of their profession. Most of the respondents (36.7%) were working in a general hospital.

Of the respondents 16 (32%) always screen patients for S. aureus nasal carriage before treatment, 10 (20%) did not screen but treat all patients before surgery. The reason accounted for not screening patients prior to treatment is “not cost-effective”. When treatment is applied,  92% (24) treats patients with nasal ointment (mupirocin) and chlorhexidine gluconate medicated soap. Thirteen respondents (50%) start the treatment a week before surgery. More than half of the responders noticed, after registration SSIs, an SSI reduction after implemented treatment (16;54%).

Although the response rate on the survey concerning screening and treatment of patients on S. aureus nasal carriage undergoing a knee or hip replacement was low, this study shows that more than the half of the respondents  (26; 52%) have a preventive strategy of nasal S. aureus decolonization applied to patients prior to orthopaedic surgery in the Netherlands. 54% of the respondents noticed, after implemented treatment, a reduction of SSI. 

In terms of cost-effectiveness Kirkland et al calculated the excess total direct cost attributable to SSIs to be 5.038 dollar per infected patient11. Reducing the incidence of infection to only 1 percent can substantially decrease morbidity and mortality and reduce the economic burden for patients and hospitals. Recent research shows that a reduction in the amount of S. aureus SSIs reduces 1-year mortality in surgical patients undergoing clean procedures12.

Taking all this into consideration the recommendation is that all patients undergoing orthopaedic knee or hip replacement in hospitals and private clinics in the Netherlands must be treating on S. aureus nasal carriage with mupirocin ointment with or without a chlorhexidine gluconate soap.


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