1 Orthopedic Department, Arak university of medical sciences, Arak, Iran

2 Bone and Joint Reconstruction Research Center, Shafa Yahyaian Hospital, Iran university of medical sciences, Tehran, Iran

3 Department of Microbiology and Immunology, Arak University of Medical Sciences, Arak, Iran

4 Orthopedic Surgery, Valiasr Hospital, Arak University of Medical Sciences


Background: Periprosthetic joint infection is a devastating complication of total joint arthroplasty. It seems that the
patient’s skin, nose, throat, and urine are important sites for microbial colonization. Colonization with staphylococcus
aureus, especially methicillin resistant increases the risk of periprosthetic joint infection. The aim of this study was to
assess the prevalence of staphylococcus aureus colonization in patients candidate for arthroplasty in central Iran as
well as cost-effectiveness of decolonization program for prevention of post-arthroplasty infection.
Methods: A total of 226 patient candidates for total joint arthroplasty were enrolled in this prospective cross-sectional
study between January 2014 and January 2016. Specimens from nose, throat, groin skin, and urine were sent for
bacteriologic culture and sensitivity test. Analysis cost-effectiveness was then performed for decolonization programme.
Results: Patients had positive cultures from nose (15.9%), throat (4.4%), groin skin (3.1%), and urine (0.9%). In
general, 20.8% of the patients had positive cultures for staphylococcus aureus, among whom, 1.8% were methicillin
resistant. Based on cost-effectiveness analysis, decolonization program leads to 80% reduction in costs.
Conclusion: According to our results, although colonization with methicillin sensitive staphylococcus aureus in patients
undergoing hip or knee arthroplasty is lower than other studies but colonization with methicillin resistant staphylococcus
aureus is similar to others. Also, decolonization programme in these patients was found to be very cost-effective.
Level of evidence: II


Main Subjects

1. Ghaffari NF, Taghizadeh S. The prevalence of
patellofemoral joint dysfunction in female students
with 18-25 Y/O. J Urmia Univ Med Sci. 2003;
2. Parvizi J, Bender B, Saleh KJ, Brown TE, Schmalzried
TP, Mihalko WM. Resistant organisms in infected
total knee arthroplasty: occurrence, prevention, and
treatment regimens. Instruct Course Lect. 2008;
3. Ip D, Yam SK, Chen CK. Implications of the changing
pattern of bacterial infections following total joint
replacements. J Orthop Surg. 2005; 13(2):125-30.
4. Barakate MS, Yang YX, Foo SH, Vickery AM, Sharp
CA, Fowler LD, et al. An epidemiological survey
of methicillin-resistant Staphylococcus aureus in
a tertiary referral hospital. J Hosp Infect. 2000;
5. Jernigan JA, Clemence MA, Stott GA, Titus MG,
Alexander CH, Palumbo CM, et al. Control of
methicillin-resistant Staphylococcus aureus at a
university hospital: one decade later. Infect Control
Hosp Epidemiol. 1995; 16(12):686-96.
6. Herwaldt LA. Control of methicillin-resistant
Staphylococcus aureus in the hospital setting. Am J
Med. 1999; 106(5A):11S-8S.
7. Fishbain JT, Lee JC, Nguyen HD, Mikita JA, Mikita
CP, Uyehara CF, et al. Nosocomial transmission
of methicillin-resistant Staphylococcus aureus: a
blinded study to establish baseline acquisition rates.
Infect Control Hosp Epidemiol. 2003; 24(6):415-21.
8. Cohen SH, Morita MM, Bradford M. A seven-year
experience with methicillin-resistant Staphylococcus
aureus. Am J Med. 1991; 91(3):S233-7S.
9. Davis KA, Stewart JJ, Crouch HK, Florez CE, Hospenthal
DR. Methicillin-resistant Staphylococcus aureus
(MRSA) nares colonization at hospital admission and
its effect on subsequent MRSA infection. Clin Infect
Dis. 2004; 39(6):776-82.
10. Brumfitt W, Hamilton-Miller J. The worldwide problem
of methicillin-resistant Staphylococcus aureus. Drugs
Exp Clin Res. 1989; 16(5):205-14.
11. Kuehnert MJ, Kruszon-Moran D, Hill HA, McQuillan
G, McAllister SK, Fosheim G, et al. Prevalence of
Staphylococcus aureus nasal colonization in the United
States, 2001-2002. J Infect Dis. 2006; 193(2):172-9.
12. Gorwitz RJ, Kruszon-Moran D, McAllister SK, McQuillan
G, McDougal LK, Fosheim GE, et al. Changes in the
prevalence of nasal colonization with Staphylococcus
aureus in the United States, 2001-2004. J Infect Dis.
2008; 197(9):1226-34.
13. Yano K, Minoda Y, Sakawa A, Kuwano Y, Kondo
K, Fukushima W, et al. Positive nasal culture of
methicillin-resistant Staphylococcus aureus (MRSA)
is a risk factor for surgical site infection in orthopedics.
Acta Orthop. 2009; 80(4):486-90.
14. Parvizi J, Matar WY, Saleh KJ, Schmalzried TP, Mihalko

WM. Decolonization of drug-resistant organisms
before total joint arthroplasty. Instr Course Lect.
2009; 59(2):131-7.
15. Illingworth KD, Mihalko WM, Parvizi J, Sculco T,
McArthur B, el Bitar Y, et al. How to minimize infection
and thereby maximize patient outcomes in total joint
arthroplasty: a multicenter approach. J Bone Joint
Surg Am. 2013; 95(8):e50.
16. Weinstein MC, Siegel JE, Gold MR, Kamlet MS,
Russell LB. Recommendations of the panel on costeffectiveness
in health and medicine. JAMA. 1996;
17. Weiser MC, Moucha CS. The current state of
screening and decolonization for the prevention of
staphylococcus aureus surgical site infection after
total hip and knee arthroplasty. J Bone Joint Surg Am.
2015; 97(17):1449-58.
18. Hacek DM, Robb WJ, Paule SM, Kudrna JC, Stamos
VP, Peterson LR. Staphylococcus aureus nasal
decolonization in joint replacement surgery reduces
infection. Clin Orthop Relat Res. 2008; 466(6):1349-55.
19. Kim DH, Spencer M, Davidson SM, Li L, Shaw JD,
Gulczynski D, et al. Institutional prescreening for
detection and eradication of methicillin-resistant
Staphylococcus aureus in patients undergoing
elective orthopaedic surgery. J Bone Joint Surg Am.
2010; 92(9):1820-6.
20. Japoni-Nejad A, Rezazadeh M, Kazemian H,
Fardmousavi N, van Belkum A, Ghaznavi-Rad E.
Molecular characterization of the first communityacquired
methicillin-resistant Staphylococcus aureus
strains from Central Iran. Int J Infect Dis. 2013;
21. Wertheim HF, Melles DC, Vos MC, van Leeuwen W,
van Belkum A, Verbrugh HA, et al. The role of nasal
carriage in Staphylococcus aureus infections. Lancet
Infect Dis. 2005; 5(12):751-62.
22. Salgado CD, Farr BM, Calfee DP. Community-acquired
methicillin-resistant Staphylococcus aureus: a metaanalysis
of prevalence and risk factors. Clin Infect Dis.
2003; 36(2):131-9.
23. Hidron AI, Kourbatova EV, Halvosa JS, Terrell BJ,
McDougal LK, Tenover FC, et al. Risk factors for
colonization with methicillin-resistant Staphylococcus
aureus (MRSA) in patients admitted to an urban
hospital: emergence of community-associated MRSA
nasal carriage. Clin Infect Dis. 2005; 41(2):159-66.
24. Leonard F, Markey B. Meticillin-resistant Staphylococcus
aureus in animals: a review. Vet J. 2008;
25. O’Sullivan NP, Keane CT. Risk factors for colonization
with methicillin-resistant Staphylococcus aureus
among nursing home residents. J Hosp Infect. 2000;
26. Crum NF, Lee RU, Thornton SA, Stine OC, Wallace MR,
Barrozo C, et al. Fifteen-year study of the changing

epidemiology of methicillin-resistant Staphylococcus
aureus. Am J Med. 2006; 119(11):943-51.
27. King MD, Humphrey BJ, Wang YF, Kourbatova EV, Ray
SM, Blumberg HM. Emergence of community-acquired
methicillin-resistant Staphylococcus aureus USA 300
clone as the predominant cause of skin and soft-tissue
infections. Ann Intern Med. 2006; 144(5):309-17.
28. Diederen BM, Kluytmans JA. The emergence of
infections with community-associated methicillin
resistant Staphylococcus aureus. J Infect. 2006;
29. Faria NA, Oliveira DC, Westh H, Monnet DL, Larsen AR,
Skov R, et al. Epidemiology of emerging methicillinresistant
Staphylococcus aureus (MRSA) in Denmark:
a nationwide study in a country with low prevalence of
MRSA infection. J Clin Microbiol. 2005; 43(4):1836-42.
30. Gopal Rao G, Michalczyk P, Nayeem N, Walker G,
Wigmore L. Prevalence and risk factors for meticillinresistant
Staphylococcus aureus in adult emergency
admissions--a case for screening all patients? J Hosp
Infect. 2007; 66(1):15-21.
31. Moran GJ, Krishnadasan A, Gorwitz RJ, Fosheim GE,
McDougal LK, Carey RB, et al. Methicillin-resistant S.
aureus infections among patients in the emergency
department. N Engl J Med. 2006; 355(7):666-74.
32. Hirschmann JV. MRSA continues to invade our
communities. Massachusetts: Massachusetts Medical
Society; 2007.
33. Lu PL, Chin LC, Peng CF, Chiang YH, Chen TP, Ma L, et
al. Risk factors and molecular analysis of community
methicillin-resistant Staphylococcus aureus carriage.
J Clin Microbiol. 2005; 43(1):132-9.
34. Huang H, Flynn NM, King JH, Monchaud C, Morita M,
Cohen SH. Comparisons of community-associated
methicillin-resistant Staphylococcus aureus (MRSA)
and hospital-associated MSRA infections in Sacramento,
California. J Clin Microbiol. 2006; 44(7):2423-7.
35. Corea E, de Silva T, Perera J. Methicillin-resistant
Staphylococcus aureus: prevalence, incidence and
risk factors associated with colonization in Sri Lanka.
J Hosp Infect. 2003; 55(2):145-8.
36. Maudsley J, Stone SP, Kibbler CC, Iliffe SR, Conaty
SJ, Cookson BD, et al. The community prevalence of
methicillin-resistant Staphylococcus aureus (MRSA)
in older people living in their own homes: implications
for treatment, screening and surveillance in the UK. J
Hosp Infect. 2004; 57(3):258-62.
37. Sanderson R, Stockwell H, Wu Y. Risk factors for
pediatric community-acquired methicillin-resistant
staphylococcus aureus (MRSA). Ann Epidemiol. 2004;
38. Frazee BW, Lynn J, Charlebois ED, Lambert L,
Lowery D, Perdreau-Remington F. High prevalence
of methicillin-resistant Staphylococcus aureus in
emergency department skin and soft tissue infections.
Ann Emerg Med. 2005; 45(3):311-20.
39. Back NA, Linnemann CC Jr, Staneck JL, Kotagal UR.
Control of methicillin-resistant Staphylococcus
aureus in a neonatal intensive-care unit: use of
intensive microbiologic surveillance and mupirocin.
Infect Control Hosp Epidemiol. 1996; 17(4):227-31.
40. Abramson MA, Sexton DJ. Nosocomial methicillinresistant
and methicillin-susceptible Staphylococcus
aureus primary bacteremia: at what costs? Infect
Control Hosp Epidemiol. 1999; 20(6):408-11.
41. Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber
MJ, Karchmer AW, Carmeli Y. Comparison of mortality
associated with methicillin-resistant and methicillinsusceptible
Staphylococcus aureus bacteremia: a
meta-analysis. Clin Infect Dis. 2003; 36(1):53-9.
42. Boyce J. Strategies for controlling methicillin-resistant
Staphylococcus aureus in hospitals. J Chemother.
1995; 7(Suppl):81-5.
43. Mahieu L, Buitenweg N, Beutels P, De Dooy J.
Additional hospital stay and charges due to hospitalacquired
infections in a neonatal intensive care unit. J
Hosp Infect. 2001; 47(3):223-9.