Staphylococcus aureus Screening and Decolonization in Orthopaedic Surgery and Reduction of Surgical Site Infections

To the Editor: We read the report by Chen and colleagues with great interest. In their study, the authors studied whether Staphylococcus aureus screening and decolonization strategy reduce surgical site infections in orthopaedic surgery [3]. This question is of great concern as S aureus is a major risk factor for surgical site infections, notably in orthopaedic surgery [2, 6]. Despite some well-conducted studies, we believe that no clear conclusions can be made because of the inclusion of heterogeneous patients and the types of surgery. Chen and colleagues included 19 studies related to orthopaedic surgery in their review — many with questionable methodologies. The authors concluded that all of the studies showed a reduction in surgical site infections or wound complications by instituting S aureus screening and decolonization [3]. We disagree with this analysis. It seems the authors considered the entire data from the Bode et al. study and not data from its orthopaedic population [3]. We conducted a meta-analysis of the randomized trials studying a decolonization strategy in S. aureus nasal carriers undergoing surgery, which we will summarize here. The search strategy was conducted using the COCHRANE and MEDLINE databases. Two independent authors (EBN, PV) performed the search, using the following terms: ‘‘mupirocin’’, ‘‘Staphylococcus aureus’’, ‘‘carrier’’, and ‘‘surgery’’. The authors then searched the terms: ‘‘chlorhexidine’’, ‘‘Staphylococcus aureus’’, and ‘‘carrier’’. The authors screened the titles and abstracts for relevant studies. The authors also scanned the reference lists of selected papers to identify potentially relevant studies that could be considered for inclusion in the meta-analysis. Only randomized controlled studies with a strategy of decolonization in S aureus nasal carriers for reducing surgical site infections (whether the strategy was mupirocin alone or mupirocin plus chlorhexidine) were included. From an initial list of 160 references, the authors retained six studies [2, 4, 6–9]. The effect of the decolonization strategy was first analyzed in overall surgical patients and subsequently in orthopaedic surgical patients. Our slide (Fig. 1A–B) describes the results of our metaanalysis. When we included all of the surgical specialties in the analysis (Fig. 1A), the decolonization of S aureus nasal (Re: Chen FA, Wessel CB, Rao N. Staphylococcus aureus Screening and Decolonization in Orthopaedic Surgery and Reduction of Surgical Site Infections. Clin Orthop Relat Res. 2013;471:2383–2399). The authors certify that they, or any members of their immediate family, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons.