5 Ways to Minimize MRSA Risks

Infection Prevention

By: Mike Morsch

Published: 7/18/2019

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Take these proactive steps to prevent the common cause of joint replacement infections.


To grasp the importance of preventing methicillin-resistant Staphylococcus aureus (MRSA) infection in joint replacement patients, consider what happens if the bacteria found on skin and in nares flakes into an open surgical wound and forms an antibiotic-resistant biofilm on the implant your surgeon just placed.

The surgeon must reopen the joint to remove the infected implant and place a temporary spacer in its place, subject the patient to a 6-week course of antibiotics and perform yet another procedure 2 to 3 months later to hopefully make good on his original promise to restore the joint's natural function.

"Even after all of that, the infection eradication rate is only about 85%, which isn't great," says Scott Sporer, MD, a hip and knee replacement specialist at Rush University Medical Center in Chicago, Ill. "MRSA infections are a big deal."

To say the least. Thankfully, there are several ways to limit the risk.

1. Smart patient selection

The essential first step to preventing S. aureus infection is identifying patients who are at increased risk, and managing their risk factors before they arrive for surgery. Uncontrolled diabetes, history of smoking, kidney disease and obesity make patients more prone to infection. Diabetes can be improved with diet and medication, smokers can stop smoking, obese patients can lose weight and blood glucose levels can be managed on the day of surgery. However, some non-modifiable risk factors such as liver or kidney disease might preclude patients from undergoing joint replacement surgery because the procedure's risks outweigh its potential benefits.

"Patient optimization is probably the most important factor in minimizing the risk of infection," says Gregory Deirmengian, MD, an associate professor of orthopedic surgery at the Rothman Orthopaedic Institute in Philadelphia, Pa. "If a surgeon operates on a patient with multiple uncontrolled risk factors, no matter what else is done to prevent infection, the cards are already stacked against the case."

2. Nasal decolonization

S. aureus bacteria found in surgical sites often matches that found in patients' nares. Research has also identified S. aureus in nasal carriages as an independent risk factor of S. aureus infection after joint replacement surgery.

You can screen patients for S. aureus weeks before their procedures and treat carriers with mupirocin nasal ointment twice a day for 5 days before surgery and vancomycin plus cefazolin for pre-op antibiotic prophylaxis, says Antonia Chen, MD, MBA, director of research and arthroplasty services at Brigham and Women's Hospital in Boston, Mass. That's a viable option, but outpatient facilities are moving away from screening and instead treating patients for S. aureus, says Dr. Sporer.

"Patients who undergo joint replacements in the same-day setting tend to be younger, and it's challenging to schedule them for the screening and the follow-up appointments needed to prescribe the nasal antibiotic therapy," he says. "For logistical reasons, it makes more sense to assume everyone is a carrier when they arrive on the day of surgery, and implement nasal decolonization."

Joanne Epstein, BSN, RN, CNOR, surgical services educator at Saint Francis Hospital in Wilmington, Del., says a lack of compliance with pre-procedure antibiotic regimens is another reason to treat every patient as a carrier of S. aureus. "Our orthopedic surgeons prescribe intranasal mupirocin to total joint patients," says Ms. Epstein. "And what we have discovered when questioning patients in pre-op is that very few of them use the mupirocin as prescribed."

Nasal decolonization, therefore, "is a good option for outpatient surgery, where you may not get to test everyone and you may not be able to administer pre-operative antibiotics as needed," adds Dr. Chen. There are 2 ways to achieve nasal decolonization:

  • Intranasal povidone-iodine. Nurses at Rush Medical Center treat the nares of patients who present for joint replacement surgery with a povidone-iodine nasal solution. The nurses use a total of 4 swabs, 2 per nostril, to swab surfaces inside the nose for alternating 15-second intervals. The povidone-iodine sticks to the nares and keeps the nose from shedding S. aureus ?for 4 hours.
  • Alcohol-based antiseptic. Total joint patients who arrive at Saint Francis Hospital are given a single-use ampule, which they use to swab nasal sanitizer around each nostril — 6 times in counterclockwise and clockwise directions — an hour before they're wheeled into the OR. The ethanol antiseptic, which reduces bacterial colonization and lasts for several hours, is largely pleasant for patients for use.

Ms. Epstein says a nurse explains to the patient how to use the ethanol-based swab and why nasal decolonization is important, and watches the patient swab to make sure it's done correctly.

"There's no doubt that decolonizing the nose before surgery lowers the risk of infection," says Dr. Sporer, "but there's not yet clear evidence to suggest one method is superior to another."

3. Pre-op precautions

WELL-OILED MACHINE Expert surgical teams perform efficient surgery with shorter operative times, meaning the wound is open for less time and the risk of infection is lower.   |  Pamela Bevelhymer, RN, BSN, CNOR

Ask patients to wash their bodies with a chlorhexidine gluconate solution once a day for 5 days leading up to surgery. Patients should also shower with CHG the night before surgery. On the day of surgery, use CHG wipes in pre-op to decontaminate the area around the site. On a knee replacement patient, for example, you'd wipe from mid-thigh to mid-calf, covering the entire circumference of the leg.

Some surgeons administer intravenous tranexamic acid (TXA) in pre-op to limit intraoperative and post-op bleeding, says Dr. Deirmengian. TXA prevents the body from breaking down blood clots that have formed, which results in less perioperative and post-op bleeding. That, in turn, prevents large hematomas — which are breeding grounds for bacteria — from forming underneath tissue around the joint.

"Decreasing blood loss also significantly reduces the need for blood transfusions, which are linked to higher infection rates," adds Dr. Sporer.

Instead of giving patients potent anticoagulants to prevent post-op blood clots from forming, a growing number of joint replacement surgeons use aspirin as the sole anticoagulant, says Dr. Sporer.

4. Wound closure

Effective wound closure is also key to keeping infections at bay, because a wound that weeps after surgery is more prone to infection. Before closing the wound, make sure to copiously irrigate it with fluids.

"Whether you add antibiotics to the irrigation solution is an area of debate, but most literature suggests that it is not more effective than antibiotic-free fluid," says Dr. Deirmengian. "An active area of research includes irrigating the wound with a diluted betadine solution, and adding antibiotic powder to the joint and wound prior to closure." Dr. Sporer has stopped using staples to close wounds, opting instead to place sub-cuticular stitches to improve vascularity and blood supply at the edges of the wound, factors that have been linked to a reduction of post-op infections. He seals incisions with topical glue and covers the wound area with an occlusive dressing, which remains in place for a week following surgery to keep the area sterile and to protect the surgical site from contaminants that can cause infection.

5. Post-op diligence

The challenge with outpatient surgery is the lack of monitoring once the patient leaves the facility and the potential risk for self-inoculation once the patient is home. If the patient who is colonized with S. aureus contaminates his hands from the nose and touches the wound during a dressing change, it's possible he's self-colonizing the wound area. To lower the risk of post-discharge infection, Dr. Sporer gives his patients another dose of oral antibiotic before discharge and sends them home with a dose of TXA. He sends patients with a high body-mass index (over 40 BMI) home with a 7-day course of antibiotics. OSM

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