Rev. bras. ortop. vol.52 número6

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Review

Article

Prophylaxis

with

nasal

decolonization

in

patients

submitted

to

total

knee

and

hip

arthroplasty:

systematic

review

and

meta-analysis

夽

David

Sadigursky

a,∗

,

Henrique

Santos

Pires

a

,

Saulo

Américo

Caldas

Rios

b

,

Francisco

Luiz

Borja

Rodrigues

Filho

c

_,

_Gustavo

_Castro

_de

_Queiroz

c

_,

_Mateus

_Lemos

_Azi

a

a_Hospital_Manoel_Victorino,_Salvador,_BA,_Brazil

b_Hospital_Geral_Ernesto_Simões_Filho,_Salvador,_BA,_Brazil c_Faculdade_de_Tecnologia_e_Ciências_(FTC),_Salvador,_BA,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received11August2016 Accepted28October2016 Availableonline27October2017

Keywords: Arthroplasty Prophylaxis Infection Decontamination

a

b

s

t

r

a

c

t

Despitetheevolutionofthetotalkneeandhiparthroplastysurgery,highpostoperative com-plicationratesintheshortandlongtermstillpersist.Infectionisoneofthemostchallenging complications;duetoitsgravityandtreatmentdifficulties,prophylaxisprotocolshavebeen createdtodecreaseitsincidence.Theobjectiveofthisstudywastoevaluatetheimpact oftheprophylaxisprotocolformethicillin-resistantStaphylococcusaureusdecolonizationof thenaresinpatientspreviouslyidentifiedbyswabcultures,whoweretobesubmittedtoa totaljointarthroplasty.Asystematicreviewwithmeta-analysiswasconducted,following thePRISMA-2015protocol,usingthedescriptors:“arthroplasty”and“nasaldecolonization,” or“jointarthroplasty”and“decolonization,”or“jointarthroplasty”and“nasal decoloniza-tion,”forfinalselectionoffourobservationalstudiesfrom79referencesidentified.This studyincludedatotalsampleof10,179patients,dividedintwogroups:thecontrolgroup (4788patients)andinterventiongroup(5391patients).Itwasobservedthattheintervention group,inwhichprophylaxiswithnasaldecolonizationwasused,59(1.09%)ofthepatients developedasurgicalsiteinfection,whileinthecontrolgrouptherewere86casesof sur-gicalsiteinfection(1.79%).Thistrendrepeateditselfinallarticles,showingnopublication biases,formingahomogeneoussample.Theuseofaprophylaxisprotocolfor decoloniza-tionofmethicillin-resistantStaphylococcusaureus,reducedsurgicalsiteinfectioncasesby approximately39%.

夽

StudyconductedattheHospitalManoelVictorino,DepartamentodeOrtopediaeTraumatologia,Salvador,BA,Brazil. ∗ _{Corresponding}_author_.

E-mails:davidsad@gmail.com,dadav@hotmail.com(D.Sadigursky). http://dx.doi.org/10.1016/j.rboe.2016.10.018

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Profilaxia

com

descolonizac¸ão

nasal

em

pacientes

submetidos

a

artroplastia

total

de

joelho

e

quadril:

revisão

sistemática

com

metanálise

Palavras-chave: Artroplastia Profilaxia Infecc¸ão

Descontaminac¸ão

r

e

s

u

m

o

Apesardaevoluçãodosresultadosapósaartroplastiatotaldejoelhoequadril,ainfecção aindaéumadascausasmaisdesafiadorasparaocirurgião.Emvirtudedagravidadee dificuldadedotratamentodainfecçãoarticularperiprotética,foramcriadosprotocolosde profilaxiaparaessetipodecomplicação.Oobjetivodesteestudofoiavaliaraprofilaxia infec-ciosacomadescolonizaçãonasalpréviacontraStaphylococcusaureusresistenteàmeticilina, identificadospormeiodacoletadematerialdanasofaringeporswabsempacientescom programaçãocirúrgicadeartroplastiatotaldejoelhoeartroplastiatotaldequadril.Foi elab-oradoumestudoderevisãosistemáticacommetanálisequeusouoprotocoloPRISMA-2015, noqualforamutilizadososdescritores:arthroplastyenasaldecolonizationoujointarthroplasty edecolonizationoujointarthroplastyenasaldecolonizationnalínguainglesa.Foram seleciona-dosquatroestudosobservacionaisdentreas79referênciasidentificadas.Aamostratotal foide10.179pacientes,divididosemdoisgrupos:controle(4.788pacientes)eintervenção (5.391pacientes).Foiobservadoque,nogrupodeintervenção,noquala profilaxiacom descolonizaçãonasalfoiaplicada,59(1,09%)dospacientesdesenvolveraminfecçãodositio cirúrgico,enquantoainfecçãodositiocirúrgicofoiobservadaem86(1,79%)dospacientes nogrupocontrole.Essatendênciaserepetiuemtodososartigosestudados, nãosendo observadorviésdepublicação,constituindoemumaamostrahomogênea.Aprofilaxia pré-operatóriacomdescolonizaçãonasalparaStaphylococcusaureusresistenteàmeticilina,reduz em39%oscasosdeinfecçãopós-artroplastiasdojoelho,devendoserconsideradacomoum protocolocomplementarpeloscirurgiões.

Introduction

Totalknee(TKA)andhip(THA)arthroplastiesaresurgical

pro-ceduresthataimtoimprovequalityoflife,promotingpain

relief, functional gain,and correctionofdeformitiesofthe affectedjoint.1,2

Eachyear600,000TKAsareperformedintheUnitedStates;

by2030,a673%increaseindemandisexpectedworldwide.

InBrazil,thenumberofTKAsisestimatedtorangebetween

60,000and70,000peryear.3,4

Despitetheevolutionofarthroplastyresults,complications inthepostoperativeperiod,bothinshort-andlong-term,still persist.Postarthroplastyinfection isoneofthemost chal-lengingcausesofcomplicationforthesurgeon.5,6_The_rate_of

post-TKAsurgicalsiteinfections(SSI)canvarybetween0.5% and23%,andhasanimpactofroughlyU$300millioninNorth Americancountries.7 _SSI_is_one_of_the_main_infection_types

associatedwithhealthcare,accountingfor17%ofthose in

theUnitedStatesand37%worldwide,accordingtotheWorld

HealthOrganization(WHO).7–10

Due to the seriousness and difficulty of treatment of

periprosthetic infections (PI), the development ofeffective

measurestominimizetheseratesisnecessary;prophylactic

measuresinthepreoperativeperiodofTKAhavebeen

demon-stratedintheliterature.2,10

Parvizi et al.2 _have _developed _a _protocol _that

summa-rizesthemosteffectiveand provenprophylacticmeasures.

Thesemeasures includetheassessment ofnasal

coloniza-tion by Staphylococcus aureus and its methicillin-resistant

strain (MRSA).However,thereisstillno consensusfor

rec-ommending universal screening, despite the fact that the

decolonizationofMRSAcarriersdecreasestheSSIrate.10

Amongthepostoperativehospitalinfections,S.aureushas beenreportedasthemainpathogenisolatedincultureexams.

HighlevelsofnasalcolonizationbyMRSAstrainsmaybea

riskfactorforSSIonset.11_The_nasal_epithelium _stands_out

asthesiteofgreatestcolonization;itsprevalencereaches,on

average,40%intheadultpopulation.Aspartofthehuman

microbiota,saidbacteriumdoesnotconstituteariskandcan becarriedforalongperiodwithoutdamagetothehealthof individuals.12

Collectingsamplesfromthenostrilswiththeswab

tech-nique allows the identification of MRSA by culture or by

polymerasechainreaction(PCR)test;bothpresenthigh posi-tivepredictivevalueandspecificity.13_This_method_is_indicated

forMRSAscreeningfromthenasalregionofpatientswhoare candidatesforTKAandTHA.14

Topicalantibiotics,whichactonS.aureusstrains,are indi-catedasaprophylacticmethod.Topicalmupirocinisthemost

frequentlyusedantibioticandrecommendedforpreoperative

nasaldecolonization(ND),andshouldbeconsideredasoneof thepillarsofanti-infectionprophylaxis.15

Thus, prophylaxis with ND forMRSA may be indicated

asanimportantprophylacticmethodforperiprostheticjoint infection.16,17_However,_studies_that_analyzed_this_subject_did

notreachaconsensusinthevalidationofprophylaxisthrough

universalMRSAassessmentinTKAandTHAcandidates.2

Thisstudy isaimedatassessingwhether infection

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Table1–InclusioncriteriaaccordingtoPICOstrategy. PICOinclusioncriteria

Indicators ResultsaccordingtoPICO

Project Cohortstudies

Population Patientsinsurgicalplanningforhipand kneearthroplasty

Intervention Prophylaxis:decolonizationforS.aureus

MRSAinidentifiedpatients Comparisons Noprophylaxis

Results Infectionrates(incidence)

identifiedthroughnasopharyngealswabcollection,isa risk-reducingfactorforSSI.

Methods

Thesystematicreviewstudy withmeta-analysiswas elabo-ratedaccordingtothePRISMAstatementprotocol(2015).18

Theliteraturewassearchedtoidentifystudiesthat evalu-atedprophylaxisasarisk-reducingfactorforSSIthroughND

forMRSAincolonizedpatients,identifiedthrough

nasopha-ryngealswabcollection.

Theinclusioncriteriafortheselectionofstudiesevaluating

prophylactictreatmentafterMRSAcolonizationassessment

inthepreoperativeperiodofpatientswhowouldundergoTKA

andTHAwerecohortstudiesinPortugueseandEnglish.

Studieswithaninadequatedescriptionandthoseinwhich theclinicaloutcomewasnottheoneproposedbytheauthors wereexcluded.Casereports,caseseriesstudies,ordescriptive reviewswerenotincluded.Incompletearticlesorthosethat didnotprovidedataregardingMRSAcolonizationinpatients

submittedtoTKAandTHAwerealsoexcluded.Articleswith

ascorelowerthan7intheNewcastle-OttawaQuality Assess-mentScale(NOS),19_which_determines_the_quality_of_the_study,

andthosethatdidnotfittherequiredLevelofScientific

Evi-dence byType ofStudy (OxfordCenter for Evidence-based

Medicine)todeterminethestudy’spublicationvaluewerealso excluded.20

Theinclusioncriteria,presentedinTable1,andthe exclu-sioncriteriaweredeterminedinaccordancewiththeobjective ofthisstudy,sothatonlyarticlesthatevaluatedtheefficacy

ofsurgicalprophylaxiswithNDforMRSAwere considered.

ThesecriteriaareshowninTable1andwerestratified accord-ingtothePICOstrategy(Patient,Intervention,Comparison, Objectives),21_in_order_to_provide_internal_validity_to_the_study.

ThedatabasesusedfortheresearchwereMEDLINE,SciELO, ScienceDirect,PubMed,Scopus,andGoogleScholar.

Thesearchwasperformedwiththefollowingdescriptors: “arthroplasty”and “nasaldecolonization,” or “joint

arthro-plasty” and “decolonization,” or “joint arthroplasty” and

“nasaldecolonization” inEnglish;“arthroplasty”and “nasal decolonization,”or“arthroplasty”and“decolonization,”“joint arthroplasty”and“nasaldecolonization”inPortuguese.

Theresultswerepresentedthroughanorganizationchart

forthe selection ofarticles; the dispersion datawas

com-piledintofunnelchartsandforestplotstobetterunderstand

the meta-analysis. The percentage of SSI in patients who

underwentarthroplastywasexpressedasarelativerisk(RR)

in 95% confidence interval (CI). The results from different

79 references retrieved in the electronic search

68 references excluded after analysis by title,

abstract, and language

11 references selected for

evaluation

7 references excluded (data not available

or inadequate study design) 4 studies selected,

including 10,179 individuals: 4,788 (47.03%) control group, 5,391 (52.96%) intervention

group

Fig.1–Organizationchartofarticleselection.PRISMA Protocol–2015.

studies were combined into a random effect model, since

notallstudiespresentedthesamemethodology.The

hetero-geneity wasanalyzedbythe chi-squared,I2_, _and_tau2 _tests

inordertoidentifydifferencesthatcouldcause biasinthe

study.Theseanalyzeswerecarriedoutwiththeappropriate

software:ReviewManager,version5.2(TheCochrane

Collab-oration,2012).

Results

Fig. 1shows the organization chartof article selection, in

which 79 references were identified aspotentially relevant

duringthesearch.Afteranalysisofthetitle,abstract,and

lan-guageofpublication,68studies didnotmeetthe inclusion

criteria.Ofthe11remainingreferences,sevenwerediscarded accordingtotheexclusioncriteria,basedonlackofdataor

inadequatestudydesign.

Aftertheselectionoffourstudies,22–25_the_total_sample_of

10,179patientswasdividedintotwogroupsforstatistical anal-ysis:noprophylaxis,4788(47.03%)anduseofprophylaxis,5391 (52.96%;Fig.1).

Table 2 shows the data collected that characterize the

four selected studies.22–25 _All _selected _studies _presented

cohortdesign,wereconsideredsuitableforsystematicreview

through meta-analysisbasedon theLevel ofScientific

Evi-dence by Type ofStudy(Oxford Centre forEvidence-based

Medicine),21_and_presented_a_minimum_value_of₇_in_the_NOS.20

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Table2–Characteristicsofselectedstudies.

Typeofstudy Totalpatients Follow-uptime Screeningmethod Prophylaxismethod Prophylaxis time

Allendeetal.(2015) Cohortstudy 793 1year Nasalswab Mupirocin 5days

Baratzetal.(2015) Cohortstudy 6514 2years Nasalswab Cephalosporin 2weeks

Haceketal.(2008) Cohortstudy 1495 2years Nasalswab Mupirocin 5days

Raoetal.(2008) Cohortstudy 1377 1year Nasalswab Mupirocin 5days

RR M–H, Random, 95% CI

0,59 [0,29, 1,21] 0,73 [0,44, 1,22] 0,50 [0,23, 1,10] 0,52 [0,24, 1,14]

0,62 [0,44, 0,86]

0,2 0,5

Experimental Control

1 2 5

RR M–H, Random, 95% CI

Fig.2–ForestPlot.RR,riskratio;CI,confidenceinterval.

etal.,24_who_evaluated_the_use_of_{cephalosporin}_for_two_weeks.

Patientswerefollowed-upfortheoutcomefortwoyearsin

thestudiesofBaratzetal.24_and_Hacek_et_al.25_;_in_the

stud-iesbyBarberoAllendeetal.,23_and_Rao_et_al.,22_patients_were

followed-upforoneyear.

InthegroupwhereMRSAprophylaxiswasperformed,59

(1.09%)ofthepatientsdevelopedSSI,whereaspostoperative

infectionwas observedin86 (1.79%)ofthe patients,which

reflectsareductionof39%inthecasesofthiscomplication (Table3).Thefollowingreductionswereobserved:40.7% in thestudybyBarberoAllendeetal.23_;_27.2%_in_the _study_by

Baratzetal.24_;_50%_in_the_study_by_Hacek_et_al.25_;_and_47.6%_in

thestudybyRaoetal.22

InthestudybyBaratzetal.,24_in_which_the_lowest_infection

rateswereobserved,theinterventiongrouppresented0.78%

casesandthecontrolgroup,1.07%(Table3).

Thefinal result ofthe weight attributedto each study,

reportedinTable3,wasbasedonthealgorithmofthe ran-domeffectmodel,whichtakesintoaccountthefactthatthere

areconsiderablemethodologicaldifferencesamongthe

stud-iesandthereforemakesadifferentiatedcalculationbasedon variance,andnotonlyonthenumberofpatients.

Table3showsthattheconfidenceintervaldidnotexceed1, whichindicatesthattheinterventiongroup,inwhich prophy-laxishadbeenperformed,presentedalowerriskofinfection. Thiswasconfirmed bythefinal statisticaltest, which pre-sentedp=0.004.

Regardingtheheterogeneitytests,whichseektoidentify

variations amongthe studies that may suggest conflicting

data, whether due to differences in design, methodology,

sampling,andbias,amongothers,thefirstparameter,tau2_,

quantitatively evaluates the heterogeneity of the results

amongthestudies,anddemonstratedthattheyoverlappedin

averyorderlyway(Fig.2),converginginalowvalue.The chi-squaredtestwasthenapplied,withitsp-value,againseeking toidentifyevidenceofheterogeneity.Finally,theI2

parame-terwasusedtoexplainhowmuchofthevariabilityamong

theresultswasassociatedwithheterogeneity;thevalueof0

(zero)indicatedthatinconsistencyamongthestudiesshould notbeanimportantfactor(Table3).

Heterogeneity,representedbythefunnelplot(Fig.3),was non-significant(tau2₌_0.0;_I2₌_0%)_and_the_occasional_estimate

ofrelativeriskwas0.62(95%CI=0.44–0.86).Therefore,no sta-tistically significantdifferences were observedbetweenthe studies(Fig.2andTable3).

InFig.3,allstudiespresenteddatafavorableto

interven-tion, with a slight tendency toward a better result in the

smallergroups,ascanbeobservedinthecomparisonwith

thevalueobtainedinthecompilationoftheresults.

Discussion

Despite theprogressininfection controlafterTKAor THA,

especially in the short term, the treatment ofestablished

infectionsinprostheticjointsremainscomplexandcostlyin termsoftimeandresources.Therefore,carefulattentionto preventinfectionsisrequired.

In thiscontext,this meta-analysisevaluatedMRSA

pro-phylaxisasanSSIrisk-reducingfactorincolonizedpatients,

identifiedbynasopharyngealswabsinTKAandTHA

candi-datesinfourcohortstudies.

ThestudydemonstratedthatprophylaxiswithNDisa pro-tectivefactor.Thismodelaccountedfora39%reductioninthe incidenceofSSI;theratedecreasedfrom1.79%inthecontrol groupto1.09%inthegroupinwhichtheinterventionwas per-formed.Thistrendwasobservedinallfourstudies,arranged inanorderlymanner,presentingstatisticallyirrelevant differ-ences,whichsuggesttheabsenceofheterogeneity.

Theresultsobtainedarereflectedintherelativerisk(0.62) and its confidence interval (0.44–0.86), which indicate that MRSAprophylaxisisaprotectivefactor.Thisprobablyarises fromtheprevalenceofthesepathogensandtheirstrains, rec-ognizedasamajorcauseofSSIinthegeneralandin-hospital population.13,26 _Infection _in _this _group _of _patients _may _be

associatedwithcolonizationofthenostrils,whichjustifiesND withtopicalmuporicinoranantibioticdrugthatactsonthis pathogen.27,28

Theimportanceofpreoperativeprophylaxiswith

investi-gationofMRSAcolonizationisobservedinstudiessuchas

thosebyBarberoAllendeetal.,23_who_performed_preoperative

prophylaxisinTKAandTHApatientswithtopicalmupirocin,

appliedinthenostrils,andchlorhexidineskinwash. When

comparingthegroupsinwhichprophylaxiswasusedornot

used,asignificantdecreaseinSSIrateswasobserved,witha

reductionof40.7%;theincidencewas4.94%inthegroupin

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Table3–Characteristicsandreviewofstudies.

Studyorsubgroup Prophylaxisused Prophylaxisnotused Weight Relativerisk

H-M,Random,95%CI

Events Total Events Total

Allendeetal.(2015) 12 409 19 384 21.7% 0.59(0.29;1.21)

Baratzetal.(2015) 27 3434 33 3080 42.6% 0.73(0.44,1.22)

Haceketal.(2008) 11 912 14 583 17.8% 0.50(0.23;1.10)

Raoetal.(2008) 9 636 20 741 18% 0.53(0.24;1.14)

Total(95%CI) 59 5391 86 4788 100% 0.62(0.44;0.86)

Heterogeneity:tau2₌_0.0;_chi2₌_0.9;_df₌₃₍_p₌_0.83);_I2₌_0%.

Overalltesteffect:Z=2.87(p=0.004).

SE(log[RR]) 0

0.2

0.4 0.3

0.5

0.2 0.5 1 2 5

RR 0.1

Fig.3–Funnelplotofthefourindependentsamples,examiningtherelationshipbetweensurgicalsiteinfectionriskand intervention.

Baratzetal.24_compared_the_incidence_of_SSI_in_patients

submittedto TKA and THA, consideringpatients who had

beentreatedwithNDforMRSAandmethicillin-sensitiveS.

aureus(MSSA)andthosewhodidnotreceiveprophylaxis.It

was observedthat the interventiongroup, treated prior to

surgerywithfirstgenerationcephalosporin,presentedan

inci-denceof 0.79%,a 27.3% reductionincomparison withthe

controlgroup,whichpresentedanincidenceof1.07%. Inthesamecontext,Haceketal.25_demonstrated_that_1.2%

ofthepatientstreatedwithNDdevelopedSSIvs.2.4%ofthose inthegroupthatwasnottreatedwithND,thatresultedina 50%reductioninSSIincidence.

Raoetal.22_compared_the_results_of_patients_who_had_or_not

undergoneNDwithnasalmupirocinandchlorhexidinebody

washinthepreoperativeperiod.TheSSIratewas1.41%inthe

prophylaxisgroupand2.69%inthecontrolgroup.Thisdata

suggestsanSSIreductionof47.6%.

ToevaluatethepercentageofpatientssubmittedtoTKA

whoremainedcolonizedbyS.aureusdespiteprophylacticND, Economedesetal.,29_in_a_pilot_study,_evaluated₆₃₄_patients

whounderwenttheprocedurebythesamesurgeonandwho

completedanNDprotocolbeforesurgery.Theauthors

demon-stratedthat33%(19of58)ofthepatientswhounderwentND continuedtopresentpositiveS.aureusculturedespite preop-erativedecolonization,inferringthatNDisnotabletoensure

thatpatientswillremaindecolonizedthroughoutthe postop-erativeperiod.TheeffectsofpersistentS.aureuscolonization inthepostoperativeperiodrequirefurtherstudiesinorderto assertthatthisgroupofpatientsisatgreaterriskofacquiring lateinfection.29

Inthesamelineofreasoning,theInternationalConsensus onPeriprostheticJointInfections,conductedbyParvizietal.,2

indicatedthatpatientscolonizedbyMRSA,especiallyinthe anteriorportionofthenostrils,haveapotentialsourceof hos-pitalandpostoperativeinfections,andthatNDwithtopical mupirocinappliedtothenostrilsforfivedayspriortosurgery wasaneffectivemeasureinreducingtheincidenceofSSI.

ThereductionofSSIrateafterMRSAscreeningand prophy-laxiscorroboratestheclinicalandpathologicalreasoning,in

whichthispathogenstandsoutasoneofthemaincausesof

infectionduetoitshighpresenceinthein-hospitaland gen-eralpopulations.TheconcernwiththeMRSAstrainishigher duetoits difficulttreatmentand control,sinceit doesnot respondtobeta-lactam antibiotics,including synthetics,as

inthe caseofmethicillin,which impliesthe needfor

ade-quate preoperativeprophylaxis.30 _Topical_mupirocin_for_ND

isthetreatmentofchoice.31_Although_some_{first-generation}

cephalosporins areefficientagainstS.aureus, thesearenot the first-choiceantimicrobial, eitherbecause theyhave

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indiscriminateusecancontributetotheemergenceof drug-resistantbacteria.32

FailuretoperformprophylaxisagainstSSIinthe preoper-ativeperiodoffersevidencefortheclinicalandpathological

reasoningregardingthiscomplicationbydemonstratingthe

increaseintheriskfactorforitsoccurrence.33

In general, the following pathogens can also cause

periprosthetic infection: Coagulase-negative staphylococci,

Streptococcus,andGram-negativeandanaerobicbacilli.34

Inthestudies byBaratzet al.,24 _Hacek_et _al.,25 _and _Rao

etal.,22_it_was_possible_to_infer_that,_in_spite_of_the_significant

reductioninSSIduetotheS.aureusscreeningandprophylaxis protocol,infectionswerealsocausedbyotherpathogens,such asPseudomonas,Enterobacter,andStreptococcus,amongothers. ThevariationintheincidenceofS.aureusisrelatedtothe existenceofassociatedriskfactorsofinfection,suchas obe-sity,earlyage,anddiabetes.35_Thus,_populations_with_different

characteristicsmaypresentdifferentSSIincidencerates.35

Duetoitsinherentcharacteristicofgroupingseveral

stud-ies, combining the individual samples and results into a

synthesis, some factors could not be approached in the

presentstudy,suchasthequantitativeandqualitativeimpact oftheprofileofdifferentpopulations onthe rateofSSI in

patientssubmittedtheTKAandTHA,thelong-termefficacy

ofthesystematicuseofthesuggestedprophylacticmethod,

aswellasthespectrumofactionoftheantibioticusedand possibleassociations.Therefore,newstudiesarerequiredto performamultivariateanalysisofthesefactors.

This systematic review with meta-analysis, as others

retrieved in the literature, is based on secondary data

extractedfromoriginalcohortstudies.However,this charac-teristicisalimitationforthemodel,sinceitdoesnotallowthe assessmentofallthedatanecessaryformultivariateanalyses andissubjecttopossiblebiases.

Theinherentcharacteristicsofthestudyconferitalevel ofevidence2accordingtotheLevelofScientificEvidenceby

TypeofStudy(OxfordCentreforEvidence-based Medicine):

systematicreviewofhomogenouscohortstudies.18

Althoughthediagnosticpossibilitieshaveimprovedwith

thedevelopment ofnewimmunological andimaging

tech-niques,thedevastatingconsequencesofaninfection,even

when early diagnosed, remain a major challenge for the

orthopedic surgeon. Thus, the development of additional

prophylaxis techniques should be investigated in order to

achieveanevengreaterreductionofthisseriouscomplication.

Nonetheless,NDscreeningforS.aureusanditsMRSAstrain

throughnasopharyngealswabcollectioncanbepresentedas

aneffectivemeasureinthereductionofSSIinTKAandTHA

thatshouldbeimplemented.

Final

considerations

Theinvestigationofnasopharyngealswabmaterialtodetect

colonization by Staphylococcus aureus and its

methicillin-resistantvariantinpatientswithindicationforTKAandTHA,

followed by decolonization with topical antibiotic therapy

withmuporicin,presentsdatathatconfirmtheeffectiveness ofitsuseasaprophylacticmethodinordertoreducetherates ofpostoperativeinfection.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.LimaALLM,PécoraJR,AlbuquerqueRM,PaulaAP,D’EliaCO, SantosALG,etal.Infectionfollowingtotalkneejoint arthroplasty:considerationsandtreatment.ActaOrtopBras. 2004;12(4):236–41.

2.ParviziJ,GehrkeT.ConsensoInternacionalemInfecc¸ões ArticularesPeriprotéticas.Availablefrom:

http://www.rbo.org.br/pdf/consensos/consensosciiap.pdf [accessed11.01.16].

3.AlmeidaRF,QueirozAA,BellotiJC,CastroFilhoJM,CohenM, NavarroRD.Approachtowardstotalkneearthroplastyin Brazil:cross-sectionalstudy.SaoPauloMedJ.

2009;127(4):190–7.

4.D’EliaCO,SantosALG,LeonhardtMC,LimaALLM,PécoraJR, CamanhoGL.Treatmentofinfectionsfollowingtotalknee arthroplasty:2-yearfollow-upoutcomes.ActaOrtopédica Bras.2007;15(3):158–62.

5.CarvalhoJúniorLH,TemponiEF,BadetR.Infecc¸ãoem artroplastiatotaldejoelho:diagnósticoetratamento.Rev BrasOrtop.2013;48(5):389–96.

6.ChoiH-R,vonKnochF,ZurakowskiD,NelsonSB,MalchauH. Canimplantretentionberecommendedfortreatmentof infectedTKA?ClinOrthopRelatRes.2011;469(4):961–9. 7.PradellaJGDP,BovoM,SallesMJC,KlautauGB,CamargoOAP,

CuryRPL.Artroplastiaprimáriadejoelhoinfectada:fatores deriscoparafalhanaterapiacirúrgica.RevBrasOrtop. 2013;48(5):432–7.

8.OrganizaçãoMundialdaSaúde.Segundodesafioglobalparaa segurançadopaciente:Cirurgiassegurassalvamvidas (orientaçõesparacirurgiaseguradaOMS).RiodeJaneiro: OrganizaçãoPan-AmericanadaSaúde;MinistériodaSaúde; AgênciaNacionaldeVigilânciaSanitária;2009.Available form:http://bvsms.saude.gov.br/bvs/publicacoes/ segurancapacientecirurgiasalvamanual.pdf. 9.CentersforDiseasePreventionandControl(CDC).The

NationalHealthcareSafetyNetwork(NHSN)Manual. Healthcarepersonnelsafetycomponentprotocol.Atlanta, GA,USA:CDC;2009.Availablefrom:

http://www.cdc.gov/nhsn/pdfs/hspmanual/hpsmanual.pdf. 10.AndersonDJ,PodgornyK,Berríos-TorresSI,BratzlerDW,

DellingerEP,GreeneL,etal.Strategiestopreventsurgicalsite infectionsinacutecarehospitals:2014update.InfectControl HospEpidemiol.2014;35(6):605–27.

11.RezapoorM,ParviziJ.Preventionofperiprostheticjoint infection.JArthroplasty.2015;30(6):902–7.

12.EvangelistaSS,OliveiraAC,EvangelistaSS,OliveiraAC. Community-acquiredmethicillin-resistantStaphylococcus aureus:aglobalproblem.RevBrasEnferm.2015;68(1):136–43. 13.HombachM,PfyfferGE,RoosM,LuckeK.Detectionof

methicillin-resistantStaphylococcusaureus(MRSA)in specimensfromvariousbodysites:performance characteristicsoftheBDGeneOhmMRSAassay,theXpert MRSAassay,andbroth-enrichedcultureinanareawithalow prevalenceofMRSAinfections.JClinMicrobiol.

2010;48(11):3882–7.

14.ParviziJ,GhanemE,SharkeyP,AggarwalA,BurnettRSJ, BarrackRL.Diagnosisofinfectedtotalknee:findingsofa multicenterdatabase.ClinOrthop.2008;466(11):2628–33. 15.CoiaJE,DuckworthGJ,EdwardsDI,FarringtonM,FryC,

(7)

ofmeticillin-resistantStaphylococcusaureus(MRSA)in healthcarefacilities.JHospInfect.2006;63Suppl.1:S1–44. 16.DaSilvaPintoCZ,AlpendreFT,StierCJN,MazieroECS,de

AlencarPGC,deAlmeidaCruzED.Characterizationofhipand kneearthroplastiesandfactorsassociatedwithinfection.Rev BrasOrtop.2015;50(6):694–9.

17.LaudermilchDJ,FedorkaCJ,HeylA,RaoN,McGoughRL. Outcomesofrevisiontotalkneearthroplastyafter methicillin-resistantStaphylococcusaureusinfection.Clin Orthop.2010;468(8):2067–73.

18.MoherD,ShamseerL,ClarkeM,GhersiD,LiberatiA, PetticrewM,etal.Preferredreportingitemsforsystematic reviewandmeta-analysisprotocols(PRISMA-P)2015 statement.SystRev.2015;4:1.

19.OttawaHospitalResearchInstitute.Availablefrom:

http://www.ohri.ca/programs/clinicalepidemiology/oxford.asp [accessed11.08.16].

20.PhillipsB,BallC,SackettD,BadenochD,StrausS,HaynesB, etal.Oxfordcentreforevidence-basedmedicinelevelsof evidence;1998.Availablefrom:

http://www.cebm.net/levelsofevidence.asp.

21.BernardoWM,NobreMRC,JateneFB.Evidencebasedclinical practice:partII–searchingevidencedatabases.RevAssoc MédicaBras.2004;50(1):104–8.

22.RaoN,CannellaB,CrossettLS,YatesAJ,McGoughR.A preoperativedecolonizationprotocolforStaphylococcus aureuspreventsorthopaedicinfections.ClinOrthop. 2008;466(6):1343–8.

23.BarberoAllendeJM,RomanykCabreraJ,MonteroRuizE, VallésPurroyA,MelgarMoleroV,AgudoLópezR,etal. EradicationofStaphylococcusaureusincarrierpatients undergoingjointarthroplasty.EnfermInfecMicrobiolClin. 2015;33(2):95–100.

24.BaratzMD,HallmarkR,OdumSM,SpringerBD.Twenty percentofpatientsmayremaincolonizedwith methicillin-resistantStaphylococcusaureusdespitea decolonizationprotocolinpatientsundergoingelectivetotal jointarthroplasty.ClinOrthop.2015;473(7):2283–90.

25.HacekDM,PauleSM,ThomsonRB,RobicsekA,PetersonLR. Implementationofauniversaladmissionsurveillanceand decolonizationprogramformethicillin-resistant

Staphylococcusaureus(MRSA)reducesthenumberofMRSA andtotalnumberofS.aureusisolatesreportedbytheclinical laboratory.JClinMicrobiol.2009;47(11):3749–52.

26.LeventT,VandeveldeD,DelobelleJ-M,LabourdetteP, LétendardJ,LesageP,etal.Infectionriskpreventionfollowing totalkneearthroplasty.OrthopTraumatolSurgRes.

2010;96(1):49–56.

27.MatarWY.Preventinginfectionintotaljointarthroplasty.J BoneJtSurgAm.2010;92Suppl.2:36.

28.NasserS.Preventionandtreatmentofsepsisintotalhip replacementsurgery.OrthopClinNorthAm.

1992;23(2):265–77.

29.EconomedesDM,DeirmengianGK,DeirmengianCA. Staphylococcusaureuscolonizationamongarthroplasty patientspreviouslytreatedbyadecolonizationprotocol:a pilotstudy.ClinOrthop.2013;471(10):3128–32.

30.PatelH,KhouryH,GirgentiD,WelnerS,YuH.Burdenof surgicalsiteinfectionsassociatedwitharthroplastyandthe contributionofStaphylococcusaureus.SurgInfect.

2016;17(1):78–88.

31.ChandrananthJ,RabinovichA,KarahaliosA,GuyS,TranP. Impactofadherencetolocalantibioticprophylaxisguidelines oninfectionoutcomeaftertotalhiporkneearthroplasty.J HospInfect.2016;93(4):423–7.

32.DuplessisC,Crum-CianfloneNF.Ceftarolineanew cephalosporinwithactivityagainstmethicillin-resistant Staphylococcusaureus(MRSA).ClinMedRevTher.2011;3, pii:a2466.

33.WuCT,ChenIL,WangJW,KoJY,WangCJ,LeeCH.Surgical siteinfectionaftertotalkneearthroplasty:riskfactorsin patientswithtimelyadministrationofsystemicprophylactic antibiotics.JArthroplast.2016;31(7):1568–73.

34.RosenthalVD.Internationalnosocomialinfectioncontrol consortium(INICC)resources:INICCmultidimensional approachandINICCsurveillanceonlinesystem.AmJInfect Control.2016;44(6):e81–90.