Maintaining good infection control policies and processes is important for orthopedic surgeons, especially as Medicare and private insurance companies move toward a pay-for-performance model of coverage. Patients with surgical site infections after total joint replacements increase their length of stay at the hospital from seven to 10 days on average and more than $10 billion is spent annually on treatment of surgical site infections. Calin Moucha, MD, associate chief of joint replacement and assistant professor at Mount Sinai Medical Center in New York City, discusses eight steps orthopedic surgeons and patients can take preoperatively to reduce the risk of surgical site infection during total joint replacements.
1. Recommend smoking patients take a cessation program. Patients who smoke have up to a 300 percent greater risk of incurring a surgical site infection because nicotine affects wound healing. "Smoking is the single most important modifiable risk factor for postoperative complication," says Dr. Moucha. "Elective surgery patients enrolled in a smoking cessation program even four to six weeks before surgery to diminish the risk of infection. They don't have to postpone surgery for a year because even the short program helps. Quitting smoking isn't the easiest thing to do, but it can make some dramatic differences."
2. Manage glucose in patients with diabetes. Diabetes is one of the biggest comorbidities for many total joint replacement patients. While surgeons can't get rid of diabetes preoperatively, there are steps they can take to diminish the risk of a postoperative surgical site infection. "If you can get better control of glucose immediately before and after surgery, that really makes a difference," says Dr. Moucha. "Also, work with the patient's primary care physician to communicate about the individual's condition as early as possible before surgery. In that way long term glucose control, as measured by Hemoglobin A1C, can also be optimized." Glucose management is also helpful to reduce the risk of infection in patients who are hyperglycemic but not necessarily diagnosed with diabetes.
3. Advise obese patients not to diet before surgery. Orthopedic surgeons are seeing a huge increase in the number of total knee and hip replacements in obese patients. These patients are at an increased risk of infection and they must be managed differently from other patients. "It's very important to counsel obese patients preoperatively on several things," says Dr. Moucha. "Tell them not to go on a diet right before surgery because they could become malnourished. When people diet they can go into a catabolic state, which isn't good for an elective procedure." Surgeons also need to work closely with the anesthesiologist preoperatively to make sure the antibiotic dosage is appropriate. Patients who are overweight will need a higher dosage than patients who have a healthy body mass index.
Identifing malnourished patients and making sure they receive help before surgery is also important. Malnourished bodies can't heal wounds, which means making an incision in an undernourished patient could be risky. Elderly patients, especially those with arthritis, are at risk because they may have trouble accessing food. Patients with a history of alcoholism or other chronic illnesses, such as kidney failure, may also be malnourished. "These patients need to be tested before surgery so we can optimize their outcomes," says Dr. Moucha. Blood tests can help the surgeon assess the patient's nutrition when a problem is suspected.
4. Oral Health. If the patient has gingivitis, bad breath or a tooth infection, the bacteria can travel though the blood stream and get into the surgical site. "If the patient has an obvious abscess, make sure they see a dentist before elective surgery," he says.
5. Speak with a rheumatologist before operating on patients with inflammatory arthropathies. Patients with rheumatoid arthritis or other inflammatory arthropathies are often on a variety of medications and steroids, some of which need to be stopped before the surgery. Speak with a rheumatologist to identify which medications should be stopped before surgery. For example, many anti-inflammatory medications, depending on their half-life, could increase the risk of infection. Disease-modifying drugs are also often targeted as medications the patient should stop taking before surgery.
6. Test for bacterial colonization. Many orthopedic surgeons are beginning to test patients for methicilling sensitive staphycolococcus aureus (MSSA) and methicillin resistant staphylococcus aureus (MRSA) colonization before surgery. These bacteria are found the nose of about 30 percent of patients, which makes these individuals 200-900 percent more likely to develop an infection. "The studies have shown that patients undergoing elective surgery may benefit from being tested for bacteria in their noses," says Dr. Moucha. If the patient does have MSSA or MRSA, surgeons can recommend mupirocin ointment to their nares as well as chlorhexidine baths for five baths prior to surgery.
7. Give anemic patients erythropoietin before surgery. Anemic patients often require blood transfusions after surgery, and blood transfusions put the patient at a high risk for infection. Taking erythropoietin before surgery helps increase the patient's blood level, decreasing the risk of blood transfusions and infections.
8. Test revision surgery patients for previous infections. There are patients who return after receiving multiple surgeries because they are still experiencing pain. "Every time you re-operate on a patient, the risk of infection is higher," says Dr. Moucha. "You need to test patients with previous surgery to make sure they aren't coming to you with an infection." If a patient with a fracture that isn't healing, they need screws and rods put in or a total joint replacement. Sometimes, the fracture isn't healing because of an infection.
Learn more about Dr. Calin Moucha.
1. Recommend smoking patients take a cessation program. Patients who smoke have up to a 300 percent greater risk of incurring a surgical site infection because nicotine affects wound healing. "Smoking is the single most important modifiable risk factor for postoperative complication," says Dr. Moucha. "Elective surgery patients enrolled in a smoking cessation program even four to six weeks before surgery to diminish the risk of infection. They don't have to postpone surgery for a year because even the short program helps. Quitting smoking isn't the easiest thing to do, but it can make some dramatic differences."
2. Manage glucose in patients with diabetes. Diabetes is one of the biggest comorbidities for many total joint replacement patients. While surgeons can't get rid of diabetes preoperatively, there are steps they can take to diminish the risk of a postoperative surgical site infection. "If you can get better control of glucose immediately before and after surgery, that really makes a difference," says Dr. Moucha. "Also, work with the patient's primary care physician to communicate about the individual's condition as early as possible before surgery. In that way long term glucose control, as measured by Hemoglobin A1C, can also be optimized." Glucose management is also helpful to reduce the risk of infection in patients who are hyperglycemic but not necessarily diagnosed with diabetes.
3. Advise obese patients not to diet before surgery. Orthopedic surgeons are seeing a huge increase in the number of total knee and hip replacements in obese patients. These patients are at an increased risk of infection and they must be managed differently from other patients. "It's very important to counsel obese patients preoperatively on several things," says Dr. Moucha. "Tell them not to go on a diet right before surgery because they could become malnourished. When people diet they can go into a catabolic state, which isn't good for an elective procedure." Surgeons also need to work closely with the anesthesiologist preoperatively to make sure the antibiotic dosage is appropriate. Patients who are overweight will need a higher dosage than patients who have a healthy body mass index.
Identifing malnourished patients and making sure they receive help before surgery is also important. Malnourished bodies can't heal wounds, which means making an incision in an undernourished patient could be risky. Elderly patients, especially those with arthritis, are at risk because they may have trouble accessing food. Patients with a history of alcoholism or other chronic illnesses, such as kidney failure, may also be malnourished. "These patients need to be tested before surgery so we can optimize their outcomes," says Dr. Moucha. Blood tests can help the surgeon assess the patient's nutrition when a problem is suspected.
4. Oral Health. If the patient has gingivitis, bad breath or a tooth infection, the bacteria can travel though the blood stream and get into the surgical site. "If the patient has an obvious abscess, make sure they see a dentist before elective surgery," he says.
5. Speak with a rheumatologist before operating on patients with inflammatory arthropathies. Patients with rheumatoid arthritis or other inflammatory arthropathies are often on a variety of medications and steroids, some of which need to be stopped before the surgery. Speak with a rheumatologist to identify which medications should be stopped before surgery. For example, many anti-inflammatory medications, depending on their half-life, could increase the risk of infection. Disease-modifying drugs are also often targeted as medications the patient should stop taking before surgery.
6. Test for bacterial colonization. Many orthopedic surgeons are beginning to test patients for methicilling sensitive staphycolococcus aureus (MSSA) and methicillin resistant staphylococcus aureus (MRSA) colonization before surgery. These bacteria are found the nose of about 30 percent of patients, which makes these individuals 200-900 percent more likely to develop an infection. "The studies have shown that patients undergoing elective surgery may benefit from being tested for bacteria in their noses," says Dr. Moucha. If the patient does have MSSA or MRSA, surgeons can recommend mupirocin ointment to their nares as well as chlorhexidine baths for five baths prior to surgery.
7. Give anemic patients erythropoietin before surgery. Anemic patients often require blood transfusions after surgery, and blood transfusions put the patient at a high risk for infection. Taking erythropoietin before surgery helps increase the patient's blood level, decreasing the risk of blood transfusions and infections.
8. Test revision surgery patients for previous infections. There are patients who return after receiving multiple surgeries because they are still experiencing pain. "Every time you re-operate on a patient, the risk of infection is higher," says Dr. Moucha. "You need to test patients with previous surgery to make sure they aren't coming to you with an infection." If a patient with a fracture that isn't healing, they need screws and rods put in or a total joint replacement. Sometimes, the fracture isn't healing because of an infection.
Learn more about Dr. Calin Moucha.
