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New Nasal Protocol Reduces Infections in Lower Joint Replacement Surgery

Analysis  |  By Christopher Cheney  
   July 06, 2020

Avoiding infection in lower joint replacement surgery results in an average cost savings of about $100,000 per patient.

The use of an alcohol-based nasal antiseptic before surgery lowers surgical site infection (SSI) in lower joint replacement procedures, recent research shows.

In the United States, there are more than 1 million total joint replacement procedures annually, and that figure is expected to increase to 4 million by 2030. The average postoperative cost of a joint replacement infection is estimated at more than $100,000.

The recent research, which was published in the American Journal of Infection Control, focuses on Staphylococcus aureus infections—methicillin sensitive Staphylococcus aureus (MSSA) and methicillin resistant Staphylococcus aureus (MRSA).

"It has been estimated that S. aureus is the responsible pathogen in 63% of SSI occurring after total joint replacement. This is in part due to the fact that up to one third of the  population is colonized with S. aureus on  skin  and  nares. Consequently, some hospitals are focusing on nasal   decolonization of  both the patient and the surgical team in order to optimally reduce the risk of postoperative prosthetic joint infection," the study says.

The research examined the impact of pairing an alcohol-based nasal antiseptic with preoperative chlorhexidine bathing. The protocol was applied to all knee and hip replacement patients rather than targeted nasal decolonization, which avoids the cost of screening patients for MSSA and MRSA.

The study protocol featured three elements:

  • Patients were instructed to bathe with chlorhexidine the night before surgery
  • Patients received three nasal antiseptic swabs in the preoperative setting before surgery
  • One swab was applied twice each day after surgery while patients were hospitalized

Data was compared between a baseline period from November 2015 to October 2018 and the study period from November 2018 to October 2019. The research was conducted at Wellstar Cobb Hospital in Austell, Georgia. During the baseline and study periods, the 382-bed facility performed an average of 10 to 12 hip procedures and 25 to 30 knee procedures per month.

The results were significant:

  • The new decolonization protocol reduced the SSI rate for total hip surgeries from 0.91 to 0.00 per 100 procedures
  • The new decolonization protocol reduced the SSI rate for total knee surgeries from 0.36 to 0.00 per 100 procedures
  • The SSI rate reductions were estimated to avoid four joint infections annually, with a cost savings of more than $400,000

The author of the research article told HealthLeaders that the SSI rate reductions have been maintained since the study concluded in October 2019. For lower joint replacement procedures, WellStar Cobb Hospital has had only one "superficial infection" since the study ended, said Susan Franklin, RN, an infection prevention practitioner at Marietta, Georgia-based WellStar Health System.

"Additionally, after learning about the great results with total joint replacement patients, the hospital has expanded the use of the program to spine patients and 75% of spine surgeons have ordered the nasal antiseptic," Franklin said.

Low-cost interventions can achieve significant improvement in surgical site infections, she said.

"The best advice that I would offer other hospitals is that rethinking what seem to be mundane protocols in place for years can result in major positive impacts—no need to spend millions of dollars on high tech equipment or software to make a big improvement in patient care, staff utilization and satisfaction, and bottom-line costs."

Christopher Cheney is the CMO editor at HealthLeaders.


The new protocol features adding an alcohol-based nasal antiseptic to preoperative chlorhexidine bathing.

Compared to a baseline period, the surgical site infection rate for total hip surgeries was reduced from 0.91 to 0.00 per 100 procedures.

The surgical site infection rate for total knee surgeries was reduced from 0.36 to 0.00 per 100 procedures.

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