Baseline prevalence of antimicrobial resistance in patients who develop a surgical site infection in hip and knee replacements: A brief report

●Antimicrobial resistance with Chlorohexidine gluconate and mupirocin in Alberta is unknown.●81 samples with complex surgical site infections were identified in Alberta.●Of 81 samples, 43 Staphylococcus species-positive specimens were found.●Only Coagulase-negative staphylococci isolates carried resistance genes. Prior to clean surgeries, decolonization with topical antimicrobials may lead to an increase in antimicrobial resistance. To provide a baseline prevalence of resistance to topical antimicrobials, in Alberta, specimens were collected from surgical site infections following hip and knee replacements. Among 81 samples with complex surgical site infections, in 43 specimens Staphylococcus species were isolated. Only coagulase-negative staphylococci isolates carried resistance genes with 10 carrying the gene qac and 6 carrying the MupA gene. Prior to clean surgeries, decolonization with topical antimicrobials may lead to an increase in antimicrobial resistance. To provide a baseline prevalence of resistance to topical antimicrobials, in Alberta, specimens were collected from surgical site infections following hip and knee replacements. Among 81 samples with complex surgical site infections, in 43 specimens Staphylococcus species were isolated. Only coagulase-negative staphylococci isolates carried resistance genes with 10 carrying the gene qac and 6 carrying the MupA gene. A universal decolonization strategy using topical antimicrobials for reducing surgical site infections (SSIs) following hip and knee replacement was recently added to the provincial care pathway in Alberta.1Alberta Bone and Joint Institute. Hip and knee surgical care path; 2022. Accessed April 4, 2023. https://www.albertaboneandjoint.com/wp-content/uploads/2022/03/2022_Hip-and-Knee-Care-Path_FINAL.pdf.Google Scholar Decolonization prior to surgery is an intervention attempting to decontaminate patients of pathogens commonly resulting in infections in order to reduce the incidence of SSIs.2Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP). Pathogen reduction & decolonization to prevent infections; 2022. Accessed April 4, 2023. https://www.cdc.gov/drugresistance/microbial-ecology/decolonization.html.Google Scholar Alberta’s universal strategy involves decolonizing all patients of pathogens that result in SSI infections with no prescreening for these pathogens. The decolonization strategy in Alberta includes topical application of chlorhexidine gluconate (CHG) and mupirocin ointment.1Alberta Bone and Joint Institute. Hip and knee surgical care path; 2022. Accessed April 4, 2023. https://www.albertaboneandjoint.com/wp-content/uploads/2022/03/2022_Hip-and-Knee-Care-Path_FINAL.pdf.Google Scholar The rollout of the decolonization strategy began in April 2021 and was not fully implemented until the end of June 2021. The baseline prevalence of antimicrobial resistance (AMR) to topical antimicrobials in Alberta is not known. Staphylococcus aureus (SA) and coagulase-negative staphylococci (CoNS) are the most common pathogens causing SSIs.3Song Z. Borgwardt L. Høiby N. Wu H. Sørensen T.S. Borgwardt A. Prosthesis infections after orthopedic joint replacement: the possible role of bacterial biofilms.Orthop Rev. 2013; 5: 65-71Crossref PubMed Scopus (108) Google Scholar Mupirocin is an antibiotic that inhibits isoleucyl-transfer RNA, ultimately inhibiting bacterial protein and RNA synthesis.4Reiss S. Pané-Farré J. Fuchs S. et al.Global analysis of the Staphylococcus aureus response to mupirocin.Antimicrob Agents Chemother. 2012; 56: 787-804Crossref PubMed Scopus (79) Google Scholar High-level mupirocin resistance (HLMupR) is often affiliated with genes mupA and mupB.5Bathoorn E. Hetem D.J. Alphenaar J. Kusters J.G. Bonten M.J. Emergence of high-level mupirocin resistance in coagulase-negative staphylococci associated with increased short-term mupirocin use.J Clin Microbiol. 2012; 50: 2947-2950Crossref PubMed Scopus (32) Google Scholar Resistance of Staphylococcus species to CHG is commonly associated with qac genes.6Hong S.I. Lee Y.M. Park K.H. et al.Clinical and molecular characteristics of qacA- and qacB-positive methicillin-resistant Staphylococcus aureus causing bloodstream infections.Antimicrob Agents Chemother. 2019; 63e02157–e2118Crossref Scopus (10) Google Scholar The objective of this study was to assess the prevalence of resistance genes associated with CHG and mupirocin ointment in isolates of Alberta patients who developed a complex SSI with CoNS or SA, including methicillin-resistant SA (MRSA) and methicillin-sensitive SA (MSSA), after hip or knee replacement. This is a descriptive study. Patients were included if they underwent total hip or knee replacement in the 2 largest cities in Alberta where approximately 70% of the hip and knee replacements are conducted (Calgary and Edmonton) and developed a complex SSI positive for SA (MSSA and MRSA) or CoNS. Deep wound tissues were collected aseptically from patients who developed a complex SSI post hip and knee replacement, and any specimens positive for SA (MSSA and MRSA) or CoNS were used in this study. An SSI is considered complex when the infection is deep incisional or organ space.7Rennert-May E.D. Conly J. Smith S. et al.The cost of managing complex surgical site infections following primary hip and knee arthroplasty: A population- based cohort study in Alberta, Canada.Infect Control Hosp Epidemiol. 2018; 39: 1183-1188Crossref PubMed Scopus (17) Google Scholar The prevalence is described as the total number of isolates with Mup and qac resistance genes among the total number of staphylococcal isolates collected from patients who developed a complex SSI. In Alberta, provincial infection prevention control tracks complex SSIs occurring after hip and knee replacement. Therefore, all infections with SA (MSSA and MRSA) and CoNS were taken from the infection prevention control surveillance list. Microbiological samples from SSIs were collected from January 1, 2020, to July 1, 2021. Samples identified as positive for SA (MSSA and MRSA) or CoNS by Alberta Provincial Laboratories and Dynalife Laboratories in Alberta, were submitted to the center for antimicrobial resistance at Foothills Medical Center in Calgary, Alberta. Culture-positive specimens were collected on swabs which were streaked onto Difco tryptic soy agar plates, and then DNA extracts and multiplex Polymerase Chain Reaction assays tested for genotypic resistance to both mupirocin and CHG. Mupirocin resistance was determined using E-test methods defined as >512 ug/mL being HLMupR. A multiplex Polymerase Chain Reaction assay (center for antimicrobial resistance, Alberta Health Services) was used to assess for antimicrobial resistance: qac, mupA, and mupB genes. Ethics approval for this study was granted by the University of Calgary Health Ethics Research Board (REB19-1310). Descriptive statistics were used to estimate the prevalence of positive specimens with resistance to mupirocin or CHG using STATA version 17 (StataCorp). A total of 43 Staphylococcus species was isolated among 81 samples with complex SSIs. Of these 43 specimens, 26 (61%) were positive for MSSA, 13 (30%) were positive for CoNS, and 4 (9%) were positive for MRSA (Table 1). Only CoNS isolates carried resistance genes with 10 (77%) carrying the gene qac and 6 (46%) carrying the MupA gene (Table 1). No Staphylococcus isolate carried the MupB gene.Table 1Resistance among specimens collected from patients who developed a complex SSI positive for SA (MSSA and MRSA) or CoNSNo. positive specimensqac (%)MupA (%)MupB (%)qac & MupA (%)Methicillin-sensitive S aureus260 (0%)*0 (0%)0 (0%)0 (0%)Methicillin-resistant S aureus40 (0%)0 (0%)0 (0%)0 (0%)Coagulase-negative staphylococci1310 (77%)6 (46%)0 (0%)5 (38%)*Row percentages represent which are carrying genes divided by the proportion of positive specimens for MSSA (n = 26), MRSA (n = 4), and CoNS (n = 13).CoNS, coagulase-negative staphylococci; MRSA, methicillin-resistant SA; MSSA, methicillin-sensitive SA; SSI, surgical site infections; SA, Staphylococcus aureus. Open table in a new tab *Row percentages represent which are carrying genes divided by the proportion of positive specimens for MSSA (n = 26), MRSA (n = 4), and CoNS (n = 13). CoNS, coagulase-negative staphylococci; MRSA, methicillin-resistant SA; MSSA, methicillin-sensitive SA; SSI, surgical site infections; SA, Staphylococcus aureus. Only CoNS isolates carried resistance genes associated with HLMupR and SA did not. Other literature suggests CoNS may be a reservoir for the gene MupA when HLMupR is present.8Desroches M. Potier J. Laurent F. Bourrel A.-S. Doucet-Populaire F. Decousser J.-W. Prevalence of mupirocin resistance among invasive coagulase-negative staphylococci and methicillin-resistant Staphylococcus aureus (MRSA) in France: emergence of a mupirocin-resistant MRSA clone harbouring mupA.J Antimicrob Chemother. 2013; : 1714-1717Crossref Scopus (58) Google Scholar Desroches et al tested mupirocin resistant isolates for the genes MupA and MupB.8Desroches M. Potier J. Laurent F. Bourrel A.-S. Doucet-Populaire F. Decousser J.-W. Prevalence of mupirocin resistance among invasive coagulase-negative staphylococci and methicillin-resistant Staphylococcus aureus (MRSA) in France: emergence of a mupirocin-resistant MRSA clone harbouring mupA.J Antimicrob Chemother. 2013; : 1714-1717Crossref Scopus (58) Google Scholar Unlike our study, isolates included clinically relevant bacteraemia, osteoarticular infections, and deep soft tissue infections associated with devices.8Desroches M. Potier J. Laurent F. Bourrel A.-S. Doucet-Populaire F. Decousser J.-W. Prevalence of mupirocin resistance among invasive coagulase-negative staphylococci and methicillin-resistant Staphylococcus aureus (MRSA) in France: emergence of a mupirocin-resistant MRSA clone harbouring mupA.J Antimicrob Chemother. 2013; : 1714-1717Crossref Scopus (58) Google Scholar In this study, the prevalence of the MupA gene was higher in CoNS strains (5.6%) with HLMupR than in MSSA and MRSA isolates (0.8%).10Septimus E.J. Schweizer M.L. Decolonization in prevention of health care-associated infections.Clin Microbiol Rev. 2016; 29: 201-222Crossref PubMed Scopus (167) Google Scholar Consistent with our results, this study did not find the MupB gene present in any isolates.8Desroches M. Potier J. Laurent F. Bourrel A.-S. Doucet-Populaire F. Decousser J.-W. Prevalence of mupirocin resistance among invasive coagulase-negative staphylococci and methicillin-resistant Staphylococcus aureus (MRSA) in France: emergence of a mupirocin-resistant MRSA clone harbouring mupA.J Antimicrob Chemother. 2013; : 1714-1717Crossref Scopus (58) Google Scholar It is suggested that the MupB gene is a new mupirocin resistance gene that requires ongoing monitoring to detect its emergence.8Desroches M. Potier J. Laurent F. Bourrel A.-S. Doucet-Populaire F. Decousser J.-W. Prevalence of mupirocin resistance among invasive coagulase-negative staphylococci and methicillin-resistant Staphylococcus aureus (MRSA) in France: emergence of a mupirocin-resistant MRSA clone harbouring mupA.J Antimicrob Chemother. 2013; : 1714-1717Crossref Scopus (58) Google Scholar Horner et al reviewed the prevalence of chlorhexidine resistance in staphylococci and 3 articles reviewed SA and CoNS.9Horner C. Mawer D. Wilcox M. Reduced susceptibility to chlorhexidine in staphylococci: is it increasing and does it matter?.J Antimicrob Chemother. 2012; 67: 2547-2559Crossref PubMed Scopus (206) Google Scholar Among these articles, the qac gene was reported at a higher prevalence in SA than CoNS which differs from our study.9Horner C. Mawer D. Wilcox M. Reduced susceptibility to chlorhexidine in staphylococci: is it increasing and does it matter?.J Antimicrob Chemother. 2012; 67: 2547-2559Crossref PubMed Scopus (206) Google Scholar The development of AMR after short-term use of mupirocin is rare; however, the prevalence of AMR with CHG and HLMupR is more likely to result in decolonization failure.10Septimus E.J. Schweizer M.L. Decolonization in prevention of health care-associated infections.Clin Microbiol Rev. 2016; 29: 201-222Crossref PubMed Scopus (167) Google Scholar Therefore, continuing to monitor AMR to topical antibiotics such as CHG and mupirocin should be considered. Sample and data collection were conducted during the COVID-19 pandemic, and with changes in health care protocols and outbreaks, many hip and knee replacement surgeries were canceled. Due to the high number of surgery cancellations in Alberta, our sample size was lower than expected. Our study had limited data; therefore, we have no knowledge of the effect of topical antimicrobials and resistance patterns with nonstaphylococcal isolates. Additionally, we were unable to determine the specific CoNS species for this study. This study gives an understanding of the baseline prevalence of resistance genes associated with mupirocin and CHG in Alberta and can be used for ongoing AMR monitoring as universal decolonization becomes more prevalent. Further studies are needed to measure AMR prevalence before, during, and after implementation of a universal decolonization strategy for common, clean surgical hip, and knee replacement procedures.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.