Preoperative Methicillin-Resistant Staphylococcus aureus Colonization and Risk of Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND

Although preoperative screening and decolonization of methicillin-resistant Staphylococcus aureus (MRSA) reduce the risk of periprosthetic joint infection (PJI) and surgical site infections (SSI) after total joint arthroplasty (TJA), the residual infection risk in MRSA-colonized patients who undergo decolonization remains debated. This systematic review investigated the association between preoperative MRSA colonization and the risk of PJI and SSI after TJA.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed/Medline, Embase, Scopus, and Web of Science databases were searched until October 24, 2025. Studies examining the association of preoperative MRSA colonization with PJI and SSI risk after TJA were included. Patients were classified as MRSA positive (MRSA+) or MRSA negative (MRSA-) based on preoperative screening. All MRSA+ patients who underwent decolonization protocols. Random-effects meta-analysis was performed. Heterogeneity was assessed using I2 statistics, and meta-regression identified associated variables. There were 15 studies involving 318,487 patients (4,560 MRSA+ and 313,927 MRSA-) included.

RESULTS

Despite decolonization, MRSA+ colonization was associated with increased risk of PJI (OR [odds ratio]: 2.42, 95% CI [confidence interval]: 1.35 to 3.49; I2: 75%, P < 0.001) and SSI (OR: 2.54, 95% CI: 1.86 to 3.21; I2: 50.1%, P < 0.001) after TJA. Subgroup analyses showed stronger associations with longer follow-up periods (greater than 12 months: OR 3.01 versus ≤ 12 months: OR 2.00 for PJI; P = 0.05 for interaction).

CONCLUSIONS

Preoperative MRSA+ colonization, despite standard decolonization protocols, may still be associated with an increased risk of PJI and SSI after TJA. The methicillin-resistant staphylococcus aureus + ( MRSA+) patients require enhanced antimicrobial prophylaxis strategies, extended surveillance, and multidisciplinary management. These findings support universal MRSA screening but emphasize that decolonization alone may not normalize infection risk to that of MRSA- patients.