Project JOINTS:
Joining Organizations IN
Tackling SSIs
Screen patients for Staph aureus (SA) carriage and
decolonize SA carriers with five days of intranasal
mupirocin and at least three days of CHG soap
prior to surgery
What is Project JOINTS?
A new initiative funded by the federal government
to give participants support from IHI in the form of
in-person and virtual coaching on how to test,
implement and spread the three new evidencebased practices to prevent surgical site infection
for hip and knee arthroplasty as well as the two
applicable Surgical Care Improvement Project
(SCIP) practices.
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Support & Contributions
American Academy of Orthopaedic surgeons
(AAOS/Academy)
– “The JOINTS project is a remarkable endeavor and the Academy
looks forward to working with you to accomplish the goal of
eliminating preventable SSIs.”
AORN
Hospitals already engaged in the “new”
interventions
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Project JOINTS Website
http://www.ihi.org/ProjectJOINTS/
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Evidence suggests three new practices to
prevent surgical site infections in
patients undergoing hip and knee arthroplasty.
Interventions to Prevent SSIs for Hip and Knee
Arthroplasty
New Practices:
– Use of an alcohol-containing antiseptic agent for pre-
op skin prep
– Instruct patients to bathe or shower with chlorhexidine
gluconate (CHG) soap for at least three days before
surgery
– Screen patients for Staphylococcus aureus (SA)
and decolonize SA carriers with five days of
intranasal mupirocin and bathing or showering
with CHG soap for at least three days before
surgery
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What evidence supports Staph aureus screening and use of
intranasal mupirocin and CHG bathing or showering to decolonize
Staph aureus carriers?
Patients who carry Staph aureus in their nares or
on their skin are more likely to develop Staph
aureus SSIs. This is true for methicillin-resistant
as well as methicillin-sensitive Staph aureus.
Kluytmans JA, Mouton JW, Ijzerman EP, Vandenbroucke-Grauls CM, Maat AW,
Wagenvoort JH, et al. Nasal carriage of Staphylococcus aureus as a major risk
factor for wound infections after cardiac surgery. J Infect Dis. 1995;171:216-9.
Huang SS, Platt R. Risk of methicillin Staphylococcus aureus infection after
previous infection or colonization. Clinical Infectious Diseases. 2003;36(3):281-5.
Rao N, Cannella BA, Crossett LS, Yates AJ, McGough RL, Hamilton CW.
Preoperative Screening/Decolonization for Staphylococcus aureus to Prevent
Orthopedic Surgical Site Infection. J Arthroplasty 2011.
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What evidence supports Staph aureus screening and
use of intranasal mupirocin and CHG bathing or
showering to decolonize Staph aureus carriers?
Staph aureus carriers treated with five days of
intranasal mupirocin and CHG washes before
surgery have a 60% lower Staph aureus SSI rate
than the placebo group.
Bode LG, Voss A, Wertheim HF, et al. Preventing surgical-site infections in nasal
carriers of Staphylococcus aureus. N Engl J Med. 2010;362(1):9-17.
Preoperative screening/decolonization was associated
with fewer SSIs after elective TJA
Rao N, Cannella BA, Crossett LS, Yates AJ, McGough RL, Hamilton CW.
Preoperative Screening/Decolonization for Staphylococcus aureus to Prevent
Orthopedic Surgical Site Infection. J Arthroplasty 2011.
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Does using mupirocin eradicate Staph aureus nasal
carriage?
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Short-term nasal mupirocin (4-7 days) is an effective method for
Staph aureus eradication
90% success at one week
1% develop mupirocin resistance
Source: Systematic review (Ammerlaan HS, et al. CID 2009): 8 studies comparing
mupirocin to placebo
Does using mupirocin prevent SSIs?

Mupirocin use was associated with a significant reduction in Staph
aureus postoperative infection rates among Staph aureus carriers
Source: Systematic review (van Rijen JAC 2008): Included 4 randomized controlled
studies
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Implementing screening patients for Staph
aureus carriage and decolonize carriers with 5
days of intranasal mupirocin and at least 3 days
of CHG prior to surgery
Strategies to Accelerate Change
Screen patients for Staph aureus carriage and decolonize carriers with
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5 days of intranasal mupirocin and at least 3 days of CHG prior to
surgery
 Screen all patients for Staph aureus (methicillin resistant and
methicillin sensitive) prior to surgery, allowing enough time for those
who screen positive to be decolonized with five days of intranasal
mupirocin.
Key considerations to ensure reliable screening and
decolonization:
Assess when most preoperative assessments take place in your
setting, to evaluate whether there is sufficient time to screen and
decolonize carriers for 5 days prior to surgery.
Assess preoperative communication between the hospital, OR
department and the orthopaedic surgeons’ offices to ensure that
information on patient screening for Staph aureus and
decolonization is available at the time of surgery.
Screen patients for Staph aureus carriage and decolonize
carriers with 5 days of intranasal mupirocin and at least 3
days of CHG prior to surgery
Additional considerations in establishing a reliable
screening and decolonization process
Develop a process flow diagram, specific to your hospital
setting:
 define all necessary components of the process for patient
screening and decolonization prior to surgery
 build a process into the pre-op assessment/visit for obtaining
cultures and reliably reporting results to facilitate intranasal
mupirocin, as needed
NOTE: An example process flow diagram for Staph aureus screening &
decolonization is available in the Project JOINTS How-to Guide
Assessing Progress Over Time –
Recommended Process Measure
Percentage of patients undergoing hip or knee
replacement surgery:
who have had preoperative nasal swabs
obtained to screen for Staph aureus carriage.
with nasal swabs positive for Staph aureus who
have received five days of intranasal mupirocin
prior to surgery
NOTE: screening needs to include both methicillin resistant (MRSA)
and methicillin sensitive (MSSA) staph
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FAQs – Staph aureus screening and
decolonization
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Are there any disadvantages to decolonizing all patients with
mupirocin before hip/knee arthroplasty (versus screening patients
for Staph aureus prior to decolonization)?
It’s recommended that mupirocin use be limited to those known to be
colonized with Staph aureus.
Considerations with treating ALL patients (universal use):
1) The emergence of mupirocin resistance associated with widespread
use of mupirocin in some parts of the world
2) Cost of mupirocin – Universal mupirocin use would mean that many
patients would be using and paying for mupirocin without clear
benefit.
FAQs – Staph aureus screening and
decolonization
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Is it necessary or recommended to re-culture after
mupirocin to confirm eradication?
It’s not clear that re-culturing after preoperative mupirocin
provides information that is useful for SSI prevention.
Key considerations related to re-culturing:
Nearly all patients who receive a course of intranasal
mupirocin have negative nasal screening cultures at one week
follow-up.
It would be logistically difficult for hospitals to re-culture
patients on surgery admission and then act on these results prior
to the surgical procedure.
FAQs – Staph aureus screening and
decolonization
If a patient does not complete the entire five days of
mupirocin prior to surgery, should the remaining days be
completed following surgery?
Currently, there is no data to support a recommendation on this.
While it’s theoretically possible that it may be beneficial to
complete the course of treatment postoperatively, the logistics of
implementing this (i.e., determining the number of days the
patient received mupirocin preoperatively, ordering the remaining
doses, informing the patient/family, etc.) could be challenging.
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FAQs – Staph aureus screening and
decolonization
Should surgery be delayed if the entire five days of
mupirocin are not completed?
It’s not recommended that surgery be delayed
Every effort should be made to complete the full five days of
mupirocin before surgery
A process should be established to provide adequate time for
patients to do this whenever possible
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For More Information
The How-To Guide contains more information on all
three interventions
http://www.ihi.org/knowledge/Pages/Tools/Howto
GuidePreventSSIforHipKneeArthroplasty.aspx