Infection Control & Hospital Epidemiology

Original Articles

Cost-Effectiveness of Preoperative Nasal Mupirocin Treatment in Preventing Surgical Site Infection in Patients Undergoing Total Hip and Knee Arthroplasty: A Cost-Effectiveness Analysis

Xan F. Courvillea1a4 c1, Ivan M. Tomeka1, Kathryn B. Kirklanda2a4, Marian Birhlea4, Stephen R. Kantora1 and Samuel R. G. Finlaysona3a4

a1 Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

a2 Department of Infectious Diseases, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

a3 Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

a4 The Dartmouth Institute, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire


Objective. To perform a cost-effectiveness analysis to evaluate preoperative use of mupirocin in patients with total joint arthroplasty (TJA).

Design. Simple decision tree model.

Setting. Outpatient TJA clinical setting.

Participants. Hypothetical cohort of patients with TJA.

Interventions. A simple decision tree model compared 3 strategies in a hypothetical cohort of patients with TJA: (1) obtaining preoperative screening cultures for all patients, followed by administration of mupirocin to patients with cultures positive for Staphylococcus aureus; (2) providing empirical preoperative treatment with mupirocin for all patients without screening; and (3) providing no preoperative treatment or screening. We assessed the costs and benefits over a 1-year period. Data inputs were obtained from a literature review and from our institution's internal data. Utilities were measured in quality-adjusted life-years, and costs were measured in 2005 US dollars.

Main Outcome Measure. Incremental cost-effectiveness ratio.

Results. The treat-all and screen-and-treat strategies both had lower costs and greater benefits, compared with the no-treatment strategy. Sensitivity analysis revealed that this result is stable even if the cost of mupirocin was over $100 and the cost of SSI ranged between $26,000 and $250,000. Treating all patients remains the best strategy when the prevalence of S. aureus carriers and surgical site infection is varied across plausible values as well as when the prevalence of mupirocin-resistant strains is high.

Conclusions. Empirical treatment with mupirocin ointment or use of a screen-and-treat strategy before TJA is performed is a simple, safe, and cost-effective intervention that can reduce the risk of SSI. S. aureus decolonization with nasal mupirocin for patients undergoing TJA should be considered.

Level of Evidence. Level II, economic and decision analysis.

Infect Control Hosp Epidemiol 2012;33(2):152-159

(Received June 13 2011)

(Accepted September 22 2011)


c1 Department of Orthopaedics, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756 (