Effect of a Preoperative Decontamination Protocol onSurgical Site Infections in Patients Undergoing ElectiveOrthopedic Surgery With Hardware Implantation Serge P. Bebko, MD; David M. Green, MD; Samir S. Awad, MD, MPH IMPORTANCE Surgical site infections (SSIs), commonly caused by methicillin-resistant
Staphylococcus aureus (MRSA), are associated with significant morbidity and mortality,
specifically when hardware is implanted in the patient. Previously, we have demonstrated
that a preoperative decontamination protocol using chlorhexidine gluconate washcloths and
intranasal antiseptic ointment is effective in eradicating MRSA in the nose and on the skin of
OBJECTIVE To examine the effect of a decontamination protocol on SSIs in patients
undergoing elective orthopedic surgery with hardware implantation.
DESIGN, SETTING, AND PARTICIPANTS A prospective database of patients undergoing elective
orthopedic surgery with hardware implantation at the Michael E. DeBakey Veterans Affairs
Medical Center in Houston, Texas, was analyzed from October 1, 2012, to December 31, 2013.
Cohort groups before and after the intervention were compared.
INTERVENTIONS Starting in May 2013, during their preoperative visit, all of the patients
watched an educational video about MRSA decontamination and were given chlorhexidine
washcloths and oral rinse and nasal povidone-iodine solution to be used the night before and
the morning of scheduled surgery.
MAIN OUTCOMES AND MEASURES Thirty-day SSI rates were collected according to the
definitions of the Centers for Disease Control and Prevention National Nosocomial Infections
Surveillance. Data on demographics, comorbidities such as chronic obstructive pulmonary
disease and coronary artery disease, tobacco use, alcohol use, and body mass index were also
collected. Univariate analysis was performed between the 2 groups of patients. Multivariate
analysis was used to identify independent predictors of SSI.
RESULTS A total of 709 patients were analyzed (344 controls and 365 patients who were
decolonized). Both groups were well matched with no significant differences in age, body
mass index, sex, or comorbidities. All of the patients (100%) completed the MRSA
decontamination protocol. The SSI rate in the intervention group was significantly lower
(1.1%; 4 of 365 patients developed an SSI) than the SSI rate in the control group (3.8%; 13 of
344 patients developed an SSI) (P = .02). Multivariate logistic regression identified MRSA
decontamination as an independent predictor of not developing an SSI (adjusted odds ratio,
0.24 [95% CI, 0.08-0.77]; P = .02).
CONCLUSIONS AND RELEVANCE Our study demonstrates that preoperative MRSA
Author Affiliations: Department of
Surgery, Baylor College of Medicine,
decontamination with chlorhexidine washcloths and oral rinse and intranasal Houston, Texas (Bebko, Awad); povidone-iodine decreased the SSI rate by more than 50% among patients undergoing Department of Surgery, elective orthopedic surgery with hardware implantation. Universal decontamination using Michael E. DeBakey Veterans Affairs this low-cost protocol may be considered as an additional prevention strategy for SSIs in Medical Center, Houston, Texas(Bebko, Green, Awad).
patients undergoing orthopedic surgery with hardware implantation and warrants further Corresponding Author: Samir S.
Awad, MD, MPH, Department ofSurgery, Baylor College of Medicine,Michael E. DeBakey Veterans AffairsMedical Center, 2002 Holcombe JAMA Surg. doi:10.1001/jamasurg.2014.3480 Blvd, Room 5A-350, Houston, TX Published online March 4, 2015.
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Research Original Investigation Decontamination Protocol for Patients With Hardware Implants nually in the United States, resulting in about 300 000 was implemented starting in May 2013. From October 1, 2012, to 500 000 surgical site infections (SSIs).1 A 2009 re- to December 31, 2013, all patients undergoing elective ortho- port from the National Healthcare Safety Network estimated pedic surgery with hardware implantation were evaluated. We that, between 2006 and 2008, approximately 6000 to 20 000 included all patients who were English speakers, 18 years of SSIs have been associated with hip and knee arthroplasties an- age or older, and able to visit the clinic 5 days prior to surgery.
nually in the United States.2 Patients who underwent additional procedures fulfilling the Staphylococcus aureus is currently the most common cause previous criteria were included provided the surgical proce- of SSIs, causing as many as 37% of cases of SSI in community dures were at least 30 days apart. Patients without available hospitals. Moreover, methicillin-resistant S aureus (MRSA) has follow-up information within 30 days after surgery and those become the single most common etiologic agent of SSIs in com- who developed a chronic joint or bone infection at the surgi- munity hospitals.3 Engemann el al4 estimate that 1 case of cal site were excluded. Subsequent procedures in the same pa- MRSA SSI costs approximately $118 500 compared with ap- tient were also excluded. An SSI was defined according to the proximately $73 000 for a case of methicillin-susceptible S au- Centers for Disease Control and Prevention National Nosoco- reus infection in a patient who has had hardware implanted.
mial Infections Surveillance criteria.10,11 The difference of approximately $45 000 per infection can re-sult in a significant cost savings even if 1 case of infection is Study Intervention and Outcomes Starting May 1, 2013, the MEDVAMC Section of Orthopedic Sur- Surgical site infections, which represent the second most gery established as standard of care a decontamination pro- common type of health care–associated infection in the United tocol, consisting of the application of both chlorhexidine wash- States (ie, 22% of health care–associated infections are SSIs),5 cloths, 2%, and oral rinse, 0.12%, along with an intranasal are in most cases preventable when the patient and hospital povidone-iodine solution, 5%. The washcloths and the oral staff members adhere to proper prevention practices such as rinse were both applied once the night before and the morn- appropriate timing and type of prophylactic antibiotic used, ing of the day of surgery. The intranasal povidone-iodine so- minimizing operating room traffic, the use of hand hygiene lution was applied once in the morning of the day of surgery.
practices and nasal screening, and decolonization of S aureus Patients operated on during the period from October 1, 2012, carriers, among others.6 Of those prevention strategies that to April 30, 2013, were defined as the control group, and those have been reported to decrease SSI rates, few of them are per- operated on during the period from May 1, 2013, to December formed preoperatively. Decolonization of S aureus carriers with 31, 2013, were defined as the intervention group (Figure). All either mupirocin ointment alone or in combination with patients from the control and intervention groups under- chlorhexidine gluconate baths has demonstrated a decrease went follow-up for a 30-day postoperative period. The occur- in SSI rates.7-9 Nevertheless, the majority of previous studies rence of an SSI within that period was defined as the primary have only focused on the efficacy of nasal decontamination, outcome. With the exception of the establishment of a decon- for patients who are nasal carriers of S aureus, on SSI rates.
tamination protocol, the remaining standard perioperative pre- In the present study, we sought to assess the effect on SSIs vention measures routinely applied at the MEDVAMC, such as of a decontamination protocol consisting of the application of those recommended by the Surgical Care Improvement Proj- both chlorhexidine washcloths, 2%, and oral rinse, 0.12%, the ect, did not change during the entire study period. The fol- night before and the morning of the day of surgery, along with lowing information about patient demographics and comor- intranasal povidone-iodine solution, 5%, once the morning of bidities were gathered, including age, sex, race, body mass the day of surgery for patients undergoing elective orthope- index (calculated as weight in kilograms divided by height in dic surgery with hardware implantation. We hypothesized that meters squared), and the presence of hypertension, coronary the use of this preoperative decontamination protocol would artery disease, chronic obstructive pulmonary disease (COPD), reduce the rate of SSIs among patients undergoing elective or- chronic kidney disease, and type 2 diabetes mellitus. Data on thopedic surgery with hardware implants.
tobacco smoking, alcohol use, length of surgery, and MRSAcolonization status on the day of surgery were also collected.
Testing for MRSA nasal colonization status was performed forpatients who were admitted for more than 24 hours as per the hospital-wide screening of all admitted patients. Culture re- Study Design, Population, and Definitions sults from wounds of patients with an SSI were also collected Our prospective clinical study was conducted at the Michael when available.
E. DeBakey Veterans Affairs Medical Center (MEDVAMC) inHouston, Texas, under a protocol approved by the institu- Statistical Analysis tional review board of the center. Because this was a retro- Descriptive statistics were calculated for the data on demo- spective review of de-identified data, oral or written in- graphics, comorbidities, MRSA colonization status, and length formed consent was waived. The Veterans Affairs Surgical of surgery for both control and intervention groups. Univari- Quality Improvement Program report provides quarterly data, ate analysis was performed using a 2-sided t test, the Pearson including SSI rates for all surgical services. We found the or- χ2 test, and the Fisher exact test, as appropriate. It was per- thopedic surgical service to be a high outlier with regard to SSI formed at 2 levels. First, descriptive statistics of all variables JAMA Surgery Published online March 4, 2015 (Reprinted)
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Decontamination Protocol for Patients With Hardware Implants Original Investigation Research Figure. Patient Flowchart 723 Patients underwent elective orthopedic
surgery with hardware implantationfrom 10/01/2012 to 12/31/2013 349 Patients included from 10/01/2012
374 Patients included from 05/01/2013
to 04/30/2013 (before implementation to 12/31/2013 (after implementation of decontamination protocol) of decontamination protocol) 5 Patients excluded
8 Patients excluded
1 Patient lost to follow-up
344 Patients included in the
365 Patients included in the
intervention group were compared between control and intervention groups to greater than 24 hours (P = .001), MRSA carrier status (P = .05), verify the absence of any significant difference and minimize and the presence of an SSI (P = .02). Of the 13 patients with an selection bias. Second, we compared the rate of SSI with the SSI (3.8%) in the control group, 7 had a superficial SSI, 5 had a rest of recorded variables in order to identify possible predic- deep SSI, and 1 had an organ/space SSI (Table 2). Methicillin- tors to include in the multivariate analysis. Multivariate logis- susceptible S aureus was cultured in 4 of these 13 cases, MRSA tic regression analysis was then performed to assess the rela- in 2, Staphylococcus epidermidis in 1, and vancomycin- tionship between the development of SSI (independent resistant Enterococcus in 1 (coinfected with MRSA). One case variable) and previously identified covariates, at the primary had a negative result, and in 5 of the 13 cases, wound culture end point of 30 days. Variables were included in the multivar- was not performed. Of the 4 patients with an SSI (1.1%) in the iate analysis if the significance level reached P ≤ .10 in the uni- intervention group, 2 had a coinfection of S epidermidis and variate analysis. All analyses were calculated using IBM SPSS Enterococcus, 1 had a methicillin-susceptible S aureus infec- statistics software, version 21. All tests with P ≤. 05 were con- tion, and 1 was not tested. Of the 709 patients included in our sidered to be statistically significant.
study, 469 (66.1%) had a hospital stay of more than 24 hours(244 of 344 patients [70.9%] in the control group and 225 of365 patients [61.6%] in the intervention group). Among the 469patients tested for MRSA nasal carriage on the day of admis- sion, 14 of 244 patients (5.7%) in the control group and 5 of 225 A total of 723 patients underwent elective orthopedic surgery patients (2.2%) in the intervention group were positive (P = .05).
with hardware implants from October 1, 2012, to December 31, The results of univariate analysis comparing uninfected pa- 2013 (Figure). A total of 349 patients were included during the tients with those who acquired an SSI (ie, infected patients) study period prior to the implementation of a decontamina- are presented in Table 3. Variables that were identified as po- tion protocol, which started on May 1, 2013. Of these 349 pa- tential risk factors (P ≤ .10) included age, hypertension, COPD, tients, 5 were excluded, resulting in a control group of 344 pa- duration of surgery, and decontamination and were included tients. After the institution of the protocol, 374 patients were as predictors in the multivariate analysis. Of these, only COPD, identified, of whom 8 were excluded and 1 was lost to follow- duration of surgery, and decontamination showed a statisti- up, resulting in 365 patients for the intervention group. Of 709 cally significant difference (P < .05).
patients studied, the mean (SD) age was 56.8 (14.2) years, and The results of multivariate analysis are shown in Table 4.
646 (91.1%) were male. Hypertension was present in 445 pa- We found that COPD (odds ratio [OR], 6.76 [95% CI, 2.16- tients (62.8%), 106 patients (15.0%) had coronary artery dis- 21.19]), a duration of surgery that was longer than 150 min- ease, 64 patients (9.0%) had COPD, 33 patients (4.7%) had utes (OR, 4.59 [95% CI, 1.67-12.65]), and decontamination be- chronic kidney disease, and 143 patients (20.2%) had type 2 dia- fore surgery (OR, 0.24 [95% CI, 0.08-0.77]) are all significant betes. Of 469 patients tested for MRSA colonization status, 19 independent risk factors associated with the development of (4.1%) were found to be MRSA nasal carriers on the day of ad- an SSI within 30 days after surgery.
mission following surgery. A total of 419 patients (59.1%) weretobacco smokers, and 388 patients (54.7%) actively con-sumed alcohol. Patients had a mean (SD) body mass index of 29.7 (5.7), and the mean (SD) duration of surgery was 117.4 (58.9)minutes. Of 709 patients, 17 (2.4%) developed an SSI.
Surgical site infections remain one of the most devastating The characteristics of patients according to group are complications for orthopedic patients, leading to consider- shown in Table 1. There were no significant baseline differ- able morbidity and financial burden for both the patient and ences between the patients in the control group and those in the health care professional. Patients who develop an SSI have the intervention group besides those regarding hospital stay an 11-fold higher mortality rate than patients who do not de- (Reprinted) JAMA Surgery Published online March 4, 2015
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Research Original Investigation Decontamination Protocol for Patients With Hardware Implants Table 1. Characteristics of 709 Patients Assessed for Surgical Site Infections After Undergoing OrthopedicSurgery With Hardware Implants, by Group Patients, No. (%) Intervention Group Age, mean (SEM), y Coronary artery disease Chronic kidney disease Abbreviations: BMI, body mass index(calculated as weight in kilograms Type 2 diabetes mellitus divided by height in meters squared); Hospital stay >24 h COPD, chronic obstructive pulmonary Positive for MRSA on admission after surgerya disease; MRSA, methicillin-resistantStaphylococcus aureus.
a Percentages were derived based on the valid numbers of patients Duration of surgery, mean (SEM), min (244 patients in the control groupand 225 patients in the intervention Surgical site infection cant reductions in SSI rates, but most of them have focused on Table 2. Types of Surgical Site Infection the evaluation of nasal mupirocin and topical chlorhexidine regi- Patients, No.
mens for carriers of S aureus.
Intervention Group Over the past years, some concern has grown regarding Surgical Site Infection the development of strains of S aureus that are resistant to mupirocin. The development of resistance has been observed when mupirocin-based decolonization regimens have been used for prolonged periods of time, and it hasbeen associated with the failure of decolonization therapyand an increased risk of recolonization.16,17 In that sense, velop an SSI, with 77% of the deaths being attributable di- decontamination regimens containing nasal povidone- rectly to SSIs.1 Furthermore, the cost of the occurrence of 1 case iodine could represent a valid alternative. In a randomized of SSI caused by MRSA can reach $118 500 for patients under- controlled clinical trial comparing the efficacy of 2 preopera- going surgery with hardware implantation.4 Yet, it has been tive decontamination protocols on SSI rates after arthro- estimated that around 40% to 60% of SSI cases are actually plasty or spine fusion surgery, Phillips et al18 reported that the combination of topical chlorhexidine with a single appli- To our knowledge, this is the first study to focus on the effect cation of nasal povidone-iodine was significantly superior to of a decontamination protocol combining chlorhexidine wash- chlorhexidine plus 5 days of mupirocin at preventing all- cloths and oral rinse and intranasal povidone-iodine solution on cause deep SSIs. Furthermore, the povidone-iodine group SSI rates among patients undergoing elective orthopedic surgery had significantly fewer decontamination-related adverse with hardware implants, independent of their carrier status. We effects than did the mupirocin group.
found a significant reduction in the number of SSIs of 69.2% due Adherence to a particular decontamination regimen is a to any cause after the implementation of the decontamination cardinal factor for its success. Buehlmann et al19 showed an protocol. Furthermore, decontamination turned out to be an in- adherence rate of 87% to a 5-day regimen of nasal mupirocin, dependent protective factor against the development of an SSI chlorhexidine oral rinse, and full-body wash with chlorhexi- (OR, 0.24 [95% CI, 0.08-0.77]; P = .02). None of the patients with dine soap. Among patients who did not become decolonized, an SSI in the intervention group had an infection that was caused 87.5% did not adhere to the protocol. In contrast, our results by MRSA. In addition, we found a significant reduction in MRSA showed that the implementation of a 2-day protocol resulted nasal carrier status in the intervention group compared with the in a 100% adherence rate. In addition, a lack of adherence may control group (Table 1). Previous studies8,9,14,15 examining the ef- not only decrease the success rate but also increase the risk of fect of decontamination on SSI rates have also reported signifi- antibiotic resistance. A regimen containing nasal povidone- JAMA Surgery Published online March 4, 2015 (Reprinted)
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Decontamination Protocol for Patients With Hardware Implants Original Investigation Research Table 3. Univariate Analysis of Risk Factors Associated With the Development of Surgical Site Infections Patients, No. (%) Age, mean (SEM), y Coronary artery disease Chronic kidney disease Type 2 diabetes mellitus Abbreviations: BMI, body mass index(calculated as weight in kilograms Hospital stay >24 h divided by height in meters squared); Positive for MRSA on admission after COPD, chronic obstructive pulmonary disease; MRSA, methicillin-resistant a Percentages were derived based on Duration of surgery, mean (SEM), min the valid numbers of patients (453uninfected patients and 16 infected iodine instead of mupirocin could potentially dissipate con- Table 4. Multivariate Analysis of Independent Risk Factors Associated cerns regarding an eventual development of antibiotic resis- With the Development of SSIsa tance and could allow its application into a broader population outside S aureus carriers.
Even though Staphylococcus remains the single most com- mon organism causing SSIs in orthopedic patients,20 40% of Duration of surgery ≥150 min 4.59 (1.67-12.65) cases of SSI are still caused by other organisms such as gram- 6.76 (2.16-21.19) negative bacilli, which have been described as the second most Abbreviations: COPD, chronic obstructive pulmonary disease; OR, odds ratio; common cause of SSIs in patients undergoing primary total ar- SSIs, surgical site infections.
throplasty. We found that of the 11 patients with an SSI that a Only risk factors found to be statistically significant on multivariate analysis are was cultured, 10 (91%) had an SSI that was caused by Staphy- lococcus (4 patients [36.4%] had an SSI caused by S aureus, and2 patients [18.2%] had an SSI caused by MRSA), 3 (27.3%) de- of a 2-day regimen of chlorhexidine washcloths plus oral rinse, veloped SSIs due to Enterococcus, and 3 (27.3%) were found to along with a single application of nasal povidone-iodine, is $35 have more than 1 organism as the cause of their SSIs. Wound per patient.
culture was not performed in 6 of 17 patients (35.3%). Of these It is well known that the development of an SSI is multi- 6 patients, all had a superficial SSI. We believe that this might factorial. Besides decontamination, we found that COPD and be due to the less dramatic symptoms of superficial SSIs when a duration of surgery greater than 150 minutes were found to compared with deep or organ/space SSIs.
be independent risk factors for developing an SSI. Patients with A wider implementation of a regimen without the need of COPD had more than a 6-fold greater risk of developing an SSI S aureus carrier identification and selective decolonization than patients without COPD (OR, 6.76 [95% CI, 2.16-21.19]; would also allow for cost savings. In our institution, the cost P = .001). Likewise, patients who spent more than 2.5 hours of a polymerase chain reaction screening test for the detec- in the operating room were 4.59 times more likely to get an SSI tion of S aureus approaches $45 per patient. In turn, the cost the following 30 days than patients who spent less time in the of decontamination with mupirocin and chlorhexidine is ap- operating room (OR, 4.59 [95% CI, 1.67-12.65]; P = .003). Pre- proximately $54 per patient. Then, the implementation of a vious studies examining risk factors associated with SSIs have 5-day selective decontamination protocol of mupirocin and corroborated these findings.22 We found that a hospital stay chlorhexidine in an institution such as the MEDVAMC, with a of greater than 24 hours is a significant factor in the univari- prevalence of MRSA carriers of 18%,21 would have an esti- ate analysis (Tables 1 and 3). However, it was not a significant mated cost of $54.72 per patient. In contrast, the estimated cost independent predictor in the multivariate analysis. We be- (Reprinted) JAMA Surgery Published online March 4, 2015
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Research Original Investigation Decontamination Protocol for Patients With Hardware Implants lieve that our results might be attributed to an initial differ- the MRSA carrier status of patients before decontamination ence in proportions between the control group and the inter- was not collected, which would have allowed for an exami- vention group, leading to selection bias, and a low cutoff value nation of the effect of the protocol on decontamination of the variable.
Our study has several limitations. Our population con- In summary, our data demonstrate a significant decrease sisted mostly of male veterans with multiple comorbidities in overall SSI rates among orthopedic patients after the imple- who exclusively underwent elective orthopedic surgery with mentation of a decontamination protocol. This protocol has hardware implants, which may undermine the external additional advantages, including its shorter duration, its cost- validity. The lack of group randomization in our study also effectiveness compared with polymerase chain reaction– increases the risk of selection bias and undetected potential based protocols, and potentially fewer concerns about long- confounders. The follow-up period for detection of an SSI term antibiotic resistance. Data quality improvement through was limited to 30 days. This may have affected the sensitiv- large-scale randomized controlled clinical trials, as well as ad- ity of SSI identification, although marginally, because it has ditional studies to validate the application of the decontami- been shown that most SSIs that develop after total arthro- nation protocol to other services implanting hardware, will be plasty develop within 30 days.20 Also, information regarding the focus of future work in our enterprise against SSIs.
ARTICLE INFORMATION 5. Klevens RM, Edwards JR, Richards CL, et al.
in orthopedic surgery: the effect of mupirocin nasal Accepted for Publication: October 31, 2014.
Estimating health care–associated infections and ointment in a double-blind, randomized, deaths in U.S. hospitals, 2002. http://www.cdc.gov placebo-controlled study. Clin Infect Dis. 2002;35 Published Online: March 4, 2015.
March-April 2007. Accessed January 26, 2015.
15. Rao N, Cannella BA, Crossett LS, Yates AJ Jr,
Author Contributions: Dr Awad had full access to
6. Bosco JA III, Slover JD, Haas JP. Perioperative
McGough RL III, Hamilton CW. Preoperative all of the data in the study and takes responsibility strategies for decreasing infection: screening/decolonization for Staphylococcus aureus for the integrity of the data and the accuracy of the a comprehensive evidence-based approach. J Bone to prevent orthopedic surgical site infection: data analysis.
Joint Surg Am. 2010;92(1):232-239.
prospective cohort study with 2-year follow-up.
Study concept and design: Green, Awad.
J Arthroplasty. 2011;26(8):1501-1507.
Acquisition, analysis, or interpretation of data: 7. Kallen AJ, Wilson CT, Larson RJ. Perioperative
Bebko, Awad.
intranasal mupirocin for the prevention of 16. Patel JB, Gorwitz RJ, Jernigan JA. Mupirocin
Drafting of the manuscript: All authors.
surgical-site infections: systematic review of the resistance. Clin Infect Dis. 2009;49(6):935-941.
Critical revision of the manuscript for important literature and meta-analysis. Infect Control Hosp 17. Simor AE, Phillips E, McGeer A, et al.
intellectual content: Bebko, Awad.
Randomized controlled trial of chlorhexidine Statistical analysis: Bebko, Awad.
8. Kim DH, Spencer M, Davidson SM, et al.
gluconate for washing, intranasal mupirocin, and Administrative, technical, or material support: Institutional prescreening for detection and rifampin and doxycycline versus no treatment for eradication of methicillin-resistant Staphylococcus the eradication of methicillin-resistant Study supervision: Awad.
aureus in patients undergoing elective orthopaedic Staphylococcus aureus colonization. Clin Infect Dis.
Conflict of Interest Disclosures: None reported.
surgery. J Bone Joint Surg Am. 2010;92(9):1820-1826.
Previous Presentation: This paper was presented
9. Bode LG, Kluytmans JA, Wertheim HF, et al.
18. Phillips MS, Bosco J III, Rosenberg A, et al.
at the 38th Annual Surgical Symposium of the Preventing surgical-site infections in nasal carriers Preventing Staphylococcus aureus surgical site Association of VA Surgeons; April 6, 2014; of Staphylococcus aureus. N Engl J Med. 2010; infections: an open-label, randomized trial of nasal New Haven, Connecticut.
mupirocin ointment and nasal povidone-iodine 10. Mangram AJ, Horan TC, Pearson ML, Silver LC,
solution. In: Proceedings from the IDSA/SHEA Jarvis WR; Hospital Infection Control Practices Conference; October 20, 2012; San Diego, CA.
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site infections. Infect Dis Clin North Am. 2009;23(1): surgical site infection, 1999. Infect Control Hosp Fluckiger U, Widmer AF. Highly effective regimen for decolonization of methicillin-resistantStaphylococcus aureus carriers. Infect Control Hosp 2. Greene LR. Guide to the elimination of
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orthopedic surgery surgical site infections: Emori TG. CDC definitions of nosocomial surgical an executive summary of the Association for site infections, 1992: a modification of CDC 20. Benito N, Franco M, Coll P, et al. Etiology of
Professionals in Infection Control and Epidemiology definitions of surgical wound infections. Infect surgical site infections after primary total joint elimination guide. Am J Infect Control. 2012;40(4): Control Hosp Epidemiol. 1992;13(10):606-608.
arthroplasties. J Orthop Res. 2014;32(5):633-637.
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21. Awad SS, Palacio CH, Subramanian A, et al.
3. Anderson DJ, Sexton DJ, Kanafani ZA, Auten G,
epidemiology and microbiological aspects in Implementation of a methicillin-resistant Kaye KS. Severe surgical site infection in community trauma and orthopaedic surgery. Int Wound J. 2013; Staphylococcus aureus (MRSA) prevention bundle hospitals: epidemiology, key procedures, and the 10(suppl 1):3-8.
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