2. Nasal decolonization
About 80% of wound infections are traced to the patients' own nasal flora,
so treating patients' noses before surgery is a proven way to reduce infec-
tion risks. Also consider that 25% of individuals in a community are carri-
ers of nasal Staphylococcus aureus and 3% are MRSA carriers, so between
25% and 28% of patients entering your ORs could already be colonized.
There are 2 schools of thought when it comes to nasal decolonization:
Screen and treat MRSA carriers with a course of the nasal antibiotic
mupirocin for 5 days or assume that all patients are carriers and treat their
nares leading to and on the day of surgery with povidone iodine or an alco-
hol-based antiseptic. In the outpatient setting, it's often more practical — you
don't have to coordinate screenings weeks before procedures and patients
are subjected to additional clinic appointments — to opt for the latter option.
We ask patients and their immediate family members to apply an alco-
hol-based nasal sanitizer twice daily in the 3 days leading up to and on the
morning of surgery. They also bathe with chlorhexidine gluconate (CHG)
liquid cleanser or treat the surgical site with CHG wipes the evening before
surgery. In pre-op on the day of surgery, nurses wipe patients from head to
toe with CHG wipes and apply the nasal antiseptic.
3. Treating the wound
Craig Della Valle, MD, an orthopedic surgeon at Rush University in
Chicago, Ill., published a study in 2012 that showed bathing the surgical
wound with a dilute (0.35%) betadine lavage for 3 minutes before closure
in total hip and total knee patients reduced infection rates from more than
1% to 0.2% (osmag.net/TPGxy7). That was the gold standard in joint
replacement surgery and the protocol we used until recently when we've
begun to irrigate wounds for 3 minutes with CHG 0.05% lavage, which has
a 99.99% kill rate, before applying an antibiotic-impregnated cement
around implants and again just before wound closure.
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