Prior staphylococcal bacteremia and risk of surgical site infection after total joint arthroplasty: a nested case-control study

Background: Staphylococcus species can become dormant, causing recurrent infection after long latent periods. We sought to determine surgical site infection (SSI) risk after knee, hip, or shoulder arthroplasty with a history of staphylococcal bacteremia. Methods: Data on 7604 patients who underwent primary or revision knee, hip, or shoulder arthroplasty were reviewed. Twenty-four cases of prior documented staphylococcal bacteremia were identified. These cases were matched 1:4 to controls with similar procedures, surgical indications, and medical comorbidities. Conditional logistic regression was used to determine the risk of SSI due to prior bacteremia relative to medically similar controls. Results: Staphylococcal isolates at the time of most recent bacteremia were methicillin-sensitive S. aureus (MSSA)(9/24), methicillin-resistant S. aureus (MRSA)(8/24), and methicillin-resistant S. epidermidis (MRSE) (7/24). Prior patients with bacteremia who developed subsequent SSI (46%, 11/24 patients) all presented within 6 mo (mean 32.0 days IQR 10-142) with deep infection and positive perarticular tissue or synovial aspirate cultures. The conditional odds ratio (cOR) for SSI among prior bacteremia patients was greater than 7-fold that of controls (cOR 7.28 CI 2.21, 24.1; P<0.001). Among prior native or periprosthetic joint infection patients, prior bacteremia did not significantly increase recurrent SSI risk after two-stage arthroplasty (cOR 1.52 CI 0.29, 7.94 P=0.62). Among patients without prior joint infections, bacteremia significantly elevated future SSI risk (cOR 28.0 CI 3.44, 227, P=0.002). Conclusions: A history of staphylococcal bacteremia poses a significantly elevated risk of deep infection after hip, knee, or shoulder arthroplasty in patients without a prior native or periprosthetic joint infection.