Frequently Asked Questions
What is Project JOINTS?
Project JOINTS was an initiative funded by the federal government to spread evidence-based practices to prevent SSIs after hip and knee replacement surgery.
What is the evidence supporting the elements being promoted by Project JOINTS?
In January of 2010, the New England Journal of Medicine published articles presenting evidence to support the use of three elements shown to minimize surgical site infections:
1. Preoperative bathing or showering with chlorhexidine soap:
Instructing patients to bathe or shower with chlorhexidine soap during the 3-5 days before surgery reduces the amount of bacteria on skin. This may in turn lower the risk for surgical site infection.
2. Preoperative skin antisepsis with an alcohol-containing agent:
In a recent study, preoperative skin antisepsis with an agent containing both chlorhexidine and alcohol reduced the risk of surgical site infection by 40% compared to using povidone-iodine alone. (Other agents that include a combination of a long-acting antiseptic–an iodophor, for example–plus alcohol may be also be better than povidone iodine alone but were not evaluated in this study.) The full article can be found at: http://www.nejm.org/doi/pdf/10.1056/NEJMoa0810988.
3. Staph aureus screening and intranasal Mupirocin decolonization of Staph aureus carriers:
Preoperative nasal swabs were performed to identify patients carrying Staph aureus in another recent study. Staph aureus carriers who were decolonized using a combination of chlorhexidine bathing and nasal Mupirocin had a 60% lower risk of developing infection than Staph aureus carriers who were given placebo treatments. The full research article can be found at: http://www.nejm.org/doi/pdf/10.1056/NEJMoa0808939.
Why is alcohol a necessary ingredient in an antiseptic preoperative skin preparation?
The evidence (discussed further in the How-to Guide) suggests that preoperative skin preparations that combine alcohol (which has an immediate and dramatic killing effect on skin bacteria) with long-acting antimicrobial agents appear to be more effective at preventing SSI than povidone-iodine (an iodophor) alone. Two types of preoperative skin preparations that combine alcohol with long-acting agents are:
- CHG plus alcohol
- Iodophor plus alcohol
What concentration of alcohol is needed in an alcohol-containing antiseptic agent?
It is important to verify that the pre-op skin prep includes alcohol. Alcohol-containing pre-op skin preps are generally approximately 70% alcohol. There is a tinted CHG-alcohol prep (orange or teal) available and some hospitals have reported they find the tinting useful for greater visibility. As with all products, you should consult and follow manufacturers’ information and instructions.
Why is it recommended that patients bathe or shower with chlorhexidine gluconate (CHG) for at least three days preoperatively?
The question of the optimal number of chlorhexidine showers/baths prior to surgery is an issue where there is little scientific data to guide us. Our recommendation to shower/bathe with CHG soap for at least 3 days is mainly extrapolated from studies looking at bacterial counts on skin that suggest that repeated use of CHG soap for bathing or showering enhances the residual antimicrobial effects of CHG (i.e., the ability of CHG to reduce bacterial counts on skin not only during the immediate period after the shower but for a number of hours afterward) and that this results in progressive and more persistent reductions in bacterial counts on the skin. These study results suggest that patients may benefit from bathing or showering with CHG soap for at least 3 days before surgery in order to achieve the most benefit. Some studies evaluating the combination of preoperative CHG showering/bathing and intranasal Mupirocin such as the NEJM Bode study referenced in the How-to Guide have used 5 days of both CHG soap and Mupirocin. We don't know, though, whether the outcomes would have been different if only 3 days of chlorhexidine soap were used. Due to this uncertainty, our recommendation is to use at least 3 days of CHG soap. The disadvantages of recommending 5 days of CHG soap are mainly practical, i.e., patients would need a larger, more expensive bottle of CHG soap or the even more expensive 5-day supply of CHG wipes and compliance with an additional two days of CHG showering/bathing could be even more challenging for patients.
Should patients shower with CHG for the three days prior and the morning of surgery? Would that be a total of four showers before the surgery?
The evidence (discussed in more detail in the How-to Guide) suggests that patients bathe or shower with CHG soap for at least three days before surgery in order to achieve the most benefit. In practice, patients are often instructed to bathe or shower two days before and the morning of surgery. The goal is at least three days.
Should the whole body be bathed with the CHG soap or just the surgical site?
The CHG bath/shower prior to surgery should include the whole body “from the neck down” to avoid soap getting into the eyes, ears, nose, or mouth. Patients should also be reminded not to wash genital areas with CHG solution.
Can chlorhexidine-impregnated wipes be used instead of chlorhexidine soap?
Yes, if used correctly, the wipes may be better than chlorhexidine soap because the chlorhexidine doesn't get wiped away in the shower. One possible problem, however, is that many patients prefer showering to using the cloths, so complaince may be of concern. It may be worth asking individual patients if they're willing to use the cloths instead of showering.
Is the screening included in this initiative for Staph aureus and not just MRSA?
Yes, the intervention targets screening for Staph aureus carriage. We strongly recommend that screening include both methicillin-sensitive (MSSA) and methicillin-resistant Staph aureus (i.e., not just MRSA), using either culture or PCR testing.
Are patients who remain positive excluded from surgery until culture negative for Staph aureus?
No, it is recommended that all patients that screen positive for Staph aureus be decolonized with five (5) days of Mupirocin and at least three (3) days of chlorhexidine prior to surgery. The combination of intranasal Mupirocin and chlorhexidine bathing or showering eliminates Staph aureus, at least temporarily, from the nares and skin, the natural reservoirs where Staph aureus is most often carried. Re-culturing patients is not necessary.
Are there any disadvantages to decolonizing all patients with Mupirocin before hip/knee arthroplasty (versus screening patients for Staph aureus prior to decolonization)?
The potential disadvantages of using a universal Mupirocin strategy to consider include:
1. The emergence of Mupirocin resistance associated with widespread use of Mupirocin in some parts of the world – Whether or not a short preoperative course of Mupirocin would impact this is not yet known. Until we know more, it is probably prudent to focus Mupirocin use on the subset of patients most likely to benefit (i.e., those known to be colonized with Staph aureus);
2. Cost of Mupirocin – Universal Mupirocin use would mean that many patients would be using and paying for Mupirocin without clear benefit. (An editorial in the New England Journal of Medicine discusses this issue: Wenzel RP. Minimizing Surgical Site Infections N Engl J Med. 2010;362(1):75-77); and
3. Not differentiating MRSA- and MSSA-colonized patients misses the opportunity to adjust antibiotic prophylaxis to Vancomycin for MRSA positive patients as recommended by SCIP.
Is it necessary/recommended to re-culture after Mupirocin to confirm eradication?
Although there is no real downside to re-culturing after preoperative Mupirocin, it is not clear that this provides information that is useful for SSI prevention. Based on data summarized in a recent systematic review (Ammerlaan HS, et al. Clin Infect Dis. (2009) 49 (7): 997-1005.), nearly all patients who receive a course of intranasal Mupirocin have negative nasal screening cultures at one week follow up. We expect it would also be logistically difficult for most hospitals to re-culture patients on surgery admission and then act on these results prior to the surgical procedure. (In some hospitals, patients undergoing total hip or knee arthroplasty are scheduled for surgery on the day of admission.) Consequently, it may not be worth the effort to add this to the already complex process of preoperative screening and Staph aureus decolonization. There is very little known about whether using the results of nasal screening on the day of surgery admission to guide antimicrobial prophylaxis choice (i.e., patients with a positive nasal screen for MRSA receive vancomycin, patients with a negative nasal screen for MRSA receive cefazolin) impacts SSI risk. Using the results of repeat screening to determine the need for isolation precautions is an issue that is not really related to SSI prevention but is currently being studied.
Should surgery be delayed if the entire five days of Mupirocin are not completed?
While it’s not recommended that surgery be delayed, every effort should be made to complete the full five days of Mupirocin before surgery and a process should be established to provide adequate time for patients to do this whenever possible.
If you have decolonized a patient before surgery, do they need to be in isolation when they are an inpatient after surgery?
For patients who screen positive for methicillin-resistant Staph aureus (MRSA) and are decolonized before surgery, it is prudent to place them on contact precautions if admitted to the hospital following surgery. If a patient screens positive and is decolonized for methicillin-sensitive Staph aureus (MSSA) before surgery, it is not necessary to place them on contact precautions if admitted.
Is the use of rapid testing (PCR) or traditional culture/sensitivity for Staph aureus screening recommended?
It is important to work with the laboratory performing testing for your patients to ensure screening including both methicillin-resistant and methicillin-sensitive Staph aureus using whichever methodology is available – Polymerase Chain Reaction (PCR) assay or culture/sensitivity testing – taking into consideration the turnaround time of results, cost of testing, etc.