Hostname: page-component-78c5997874-t5tsf Total loading time: 0 Render date: 2024-11-13T00:47:15.755Z Has data issue: false hasContentIssue false
  • English
  • Français

Cost-Effectiveness of Preoperative Nasal Mupirocin Treatment in Preventing Surgical Site Infection in Patients Undergoing Total Hip and Knee Arthroplasty: A Cost-Effectiveness Analysis

Published online by Cambridge University Press:  02 January 2015

Xan F. Courville ,
Ivan M. Tomek ,
Kathryn B. Kirkland ,
Marian Birhle ,
Stephen R. Kantor  and
Samuel R. G. Finlayson
Xan F. Courville*
Affiliation:
Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire The Dartmouth Institute, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
Ivan M. Tomek
Affiliation:
Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
Kathryn B. Kirkland
Affiliation:
Department of Infectious Diseases, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire The Dartmouth Institute, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
Marian Birhle
Affiliation:
The Dartmouth Institute, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
Stephen R. Kantor
Affiliation:
Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
Samuel R. G. Finlayson
Affiliation:
Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire The Dartmouth Institute, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
*
Department of Orthopaedics, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756 (xcourville@gmail.com)
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective.

To perform a cost-effectiveness analysis to evaluate preoperative use of mupirocin in patients with total joint arthroplasty (TJA).

Design.

Simple decision tree model.

Setting.

Outpatient TJA clinical setting.

Participants.

Hypothetical cohort of patients with TJA.

Interventions.

A simple decision tree model compared 3 strategies in a hypothetical cohort of patients with TJA: (1) obtaining preoperative screening cultures for all patients, followed by administration of mupirocin to patients with cultures positive for Staphylococcus aureus; (2) providing empirical preoperative treatment with mupirocin for all patients without screening; and (3) providing no preoperative treatment or screening. We assessed the costs and benefits over a 1-year period. Data inputs were obtained from a literature review and from our institution's internal data. Utilities were measured in quality-adjusted life-years, and costs were measured in 2005 US dollars.

Main Outcome Measure.

Incremental cost-effectiveness ratio.

Results.

The treat-all and screen-and-treat strategies both had lower costs and greater benefits, compared with the no-treatment strategy. Sensitivity analysis revealed that this result is stable even if the cost of mupirocin was over $100 and the cost of SSI ranged between $26,000 and $250,000. Treating all patients remains the best strategy when the prevalence of S. aureus carriers and surgical site infection is varied across plausible values as well as when the prevalence of mupirocin-resistant strains is high.

Conclusions.

Empirical treatment with mupirocin ointment or use of a screen-and-treat strategy before TJA is performed is a simple, safe, and cost-effective intervention that can reduce the risk of SSI. S. aureus decolonization with nasal mupirocin for patients undergoing TJA should be considered.

Level of Evidence.

Level II, economic and decision analysis.

Infect Control Hosp Epidemiol 2012;33(2):152-159

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 33 , Issue 2 , February 2012 , pp. 152 - 159
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Jamsen, E, Huhtala, H, Puolakka, T, Moilanen, T. Risk factors for infection after knee arthroplasty: a register-based analysis of 43,149 cases. J Bone Joint Surg Am 2009;91(1):38–47.CrossRefGoogle Scholar
2.Khatod, M, Inacio, M, Paxton, EW, et al. Knee replacement: epidemiology, outcomes, and trends in southern California: 17,080 replacements from 1995 through 2004. Acta Orthop 2008;79(6):812–819.Google Scholar
3.Kurtz, S, Mowat, F, Ong, K, Chan, N, Lau, E, Halpern, M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am 2005;87(7):1487–1497.Google Scholar
4.Ong, KL, Kurtz, SM, Lau, E, Bozic, KJ, Berry, DJ, Parvizi, J. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplasty 2009;24(6):105–109.CrossRefGoogle ScholarPubMed
5.SooHoo, NF, Lieberman, JR, Ko, CY, Zingmond, DS. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am 2006;88(3):480–485.Google Scholar
6.Kurtz, SM, Ong, KL, Lau, E, Bozic, KJ, Berry, D, Parvizi, J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010;468:52–56.Google Scholar
7.Bozic, KJ, Ries, MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am 2005;87-A:1746–1751.Google Scholar
8.Hebert, CK, Williams, RE, Levy, RS, Barrack, RL. Cost of treating an infected total knee replacement. Clin Orthop Relat Res 1996;331:140–145.Google Scholar
9.Lavernia, C, Lee, DJ, Hernandez, VH. The increasing financial burden of knee revision surgery in the United States. Clin Orthop Relat Res 2006;446:221–226.CrossRefGoogle ScholarPubMed
10.Barrack, RL, Engh, G, Rorabeck, C, Sawhney, J, Woolfrey, M. Patient satisfaction and outcome after septic versus aseptic revision total knee arthroplasty. J Arthroplasty 2000;15(8):990–993.Google Scholar
11.Rorabeck, CH, Bourne, RB, Mulliken, BD, et al. The Nicolas Andry award: comparative results of cemented and cementless total hip arthroplasty. Clin Orthop Relat Res 1996(325):330–344.Google Scholar
12.Rao, N, Cannella, B, Crossett, LS, Yates, AJ Jr, McGough, R III. A preoperative decolonization protocol for Staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res 2008;466(6):1343–1348.CrossRefGoogle ScholarPubMed
13.Kalmeijer, MD, Coertijens, H, van Nieuwland-Bollen, PM. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind randomized, placebo-controlled study. Clin Infect Dis 2002;35:353–358.Google Scholar
14.Hacek, DM, Robb, WJ, Paule, SM, Kudrna, JC, Stamos, VP, Peterson, LR. Staphylococcus aureus nasal decolonization in joint replacement surgery reduces infection. Clin Orthop Relat Res 2008;466(6):1349–1355.Google Scholar
15.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.Google Scholar
16.Kluytmans, JA, van Belkum, A, Verbrugh, H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and assoicated risks. Clin Microbiol Rev 1997;10:505–520.Google Scholar
17.Perl, TM, Cullen, JJ, Wenzel, RP, et al. Intranasal mupirocin to prevent postoperative Staphlococcus aureus infections. New Engl J Med 2002;346:1871–1877.CrossRefGoogle Scholar
18.Gernaat-van der Sluis, A, Hoogenboom-Verdegaal, A, Edixhoven, P. Prophylactic mupirocin could reduce orthpaedic wound infections: 1,044 patients treated with mupirocin compared with 1,260 hopsital controls. Acta Orthop Scand 1998;69:412–414.Google Scholar
19.Wilcox, MH, Hall, J, Pike, H, et al. Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect 2003;54(3):196–201.CrossRefGoogle ScholarPubMed
20.Bode, LG, Kluytmans, JA, Wertheim, HF, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010;362(1):9–17.Google Scholar
21.Kallen, AJ, Wilson, CT, Larson, RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol 2005;26:916–922.Google Scholar
22.Kim, D, Spencer, M, Davidson, S, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am 2010;92:1820–1826.CrossRefGoogle ScholarPubMed
23.Ammerlaan, HS, Kluytmans, JA, Wertheim, HF, Nouwen, JL, Bonten, MJ. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis 2009;48(7):922–930.Google Scholar
24.DeFrances, C, Cullen, KA, Kozak, LJ. 2007 National hospital discharge survey: 2005 annual summary with detailed diagnosis and procedure data. http://www.cdc.gov/nchs/data/series/sr_13/sr13_165.pdf. Accessed August 26, 2011.Google Scholar
25.Horan, T, Andrus, M, Dudeck, M. CDC/NHSN surveillance definition of health care associated infection and criteria for specific types of infections in the acute setting. Am J Infect Control 2008;36:309–332.Google Scholar
26.Noskin, GA, Rubin, RJ, Schetag, JJ, et al. Budget impact analysis of rapid screening for Staphlococcus aureus colonization among patients undergoing elective surgery in US hospitals. Infect Control Hosp Epidemiol 2008;29:16–24.Google Scholar
27.Fryback, DG, Dasbach, EJ, Klein, R, et al. The Beaver Dam health outcomes study: initial catalog of health-state quality factors. Med Decis Making 1993;13:89–102.Google Scholar
28.Slover, J, Espehaug, B, Havelin, LI, et al. Cost-effectiveness of unicompartmental and total knee arthroplasty in elderly low-demand patients. J Bone Joint Surg Am 2006;88:2348–2355.Google Scholar
29.Cummins, JS, Tomek, IM, Kantor, SR, Furnes, O, Engesaeter, LB, Finlayson, SRG. Cost-effectiveness of antibiotic-impregnated bone cement used in primary total hip arthroplasty. J Bone Joint Surg Am 2009;91:634–641.CrossRefGoogle ScholarPubMed
30.Bozic, KJ, Katz, P, Cisternas, M, Ono, L, Ries, MD, Showstack, J. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am 2005;87:570–576.Google Scholar
31.Young, LS, Winston, LG. Preoperative use of mupirocin for the prevention of healthcare-associated Staphylococcus aureus infections: a cost-effectiveness analysis. Infect Control Hosp Epidemiol 2006;27:1304–1312.Google Scholar
32.Gold, MR, Siegel, JE, Russell, LB, Weinstein, MC, eds. Cost-Effectiveness in Health and Medicine. New York: Oxford University Press, 1996.CrossRefGoogle ScholarPubMed
33.van Rijen, M, Bonten, M, Wenzel, R, Kluytmans, J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev 2008(4):CD006216.Google Scholar
34.Deshpande, LM, Fix, AM, Pfaller, MA, Jones, RN; SENTRY Antimicrobial Surveillance Program Participants Group. Emerging elevated mupirocin resistance rates among staphylococcal isolates in the SENTRY Antimicrobial Surveillance Program (2000): correlations of results from disk diffusion, Etest and reference dilution methods. Diag Microbiol Infect Dis 2002;42:283–290.Google Scholar
35.Lee, AS, Macedo-Vinas, M, Francois, P, et al. Impact of combined low-level mupirocin and genotypic chlorhexidine resistance on persistent methacillin-resistant Staphylococcus aureus carriage after decolonization therapy: a case-control study. Clin Infect Dis 2011;52:1422–1430.Google Scholar
36.McConeghy, KW, Mikolich, DJ, LaPlante, KL. Agents for the decolonization of methicillin-resistant Staphylococcus aureus. Pharmacotherapy 2009;29(3):263–280.CrossRefGoogle ScholarPubMed