Limited strength evidence supports the use of universal preoperative chlorhexidine cloth
decolonization to reduce PJI after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Rationale
Periprosthetic infection after hip and knee arthroplasty is a devastating complication. Limited evidence exists to support the use of routine decolonization. Kapadia (2016) conducted a low quality randomized controlled trial (RCT) which demonstrated preoperative chlorhexidine cloths decrease risk of PJI after hip and knee arthroplasty compared to soap and water baths. Two low quality retrospective studies (Kapadia, 2016, Kapadia 2016) demonstrated the use of preoperative chlorhexidine wipes appeared to reduce the risk of periprosthetic infections after TKA and THA compared to patients who did not use them. Medium and high-risk patients had greater risk reduction in the TKA cohort whereas the THA cohort demonstrated no difference in the infection rate when stratified by risk. Reportedly, these studies were underpowered.

A low quality RCT (Sousa 2016) screened patients prior to undergoing TKA or THA for staphylococcus aureus and decolonized randomly selected carriers. Treated and untreated carriers showed no significant difference in PJI (3.4% vs 4.4%), although the study may not have been adequately powered to detect a difference.

POSSIBLE HARMS OF IMPLEMENTATION
Chlorhexidine skin decolonization appears to be safe with minimal potential risk of dermatitis and rash. There is an associated cost with decolonizing patients but this is relatively inexpensive. 

Nasal mupirocin decolonization appears to be safe with minimal potential risk of nasal irritation. There is an associated cost with decolonizing patients but this is relatively inexpensive.

FUTURE RESEARCH
Large multicenter randomized controlled trials that are sufficiently powered to measure a difference in the PJI rate that ideally stratify patients based on risk profile regarding preoperative chlorhexidine, methicillin-susceptible S. aureus and MRSA nasal screening and nasal mupirocin decolonization are needed.
  1. Kapadia,B.H., Elmallah,R.K., Mont,M.A. A Randomized, Clinical Trial of Preadmission Chlorhexidine Skin Preparation for Lower Extremity Total Joint Arthroplasty. J.Arthroplasty 2016/12; 12: 2856-2861
  2. Kapadia,B.H., Jauregui,J.J., Murray,D.P., Mont,M.A. Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Hip Arthroplasty?. Clin.Orthop.Relat.Res. 2016/7; 7: 1583-1588
  3. Kapadia,B.H., Zhou,P.L., Jauregui,J.J., Mont,M.A. Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Knee Arthroplasty?. Clin.Orthop.Relat.Res. 2016/7; 7: 1592-1598
  4. Sousa,R.J., Barreira,P.M., Leite,P.T., Santos,A.C., Ramos,M.H., Oliveira,A.F. Preoperative Staphylococcus aureus Screening/Decolonization Protocol Before Total Joint Arthroplasty-Results of a Small Prospective Randomized Trial. J.Arthroplasty 2016/1; 1: 234-239