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General Orthopaedics: S. J. Roche, D. Fitzgerald, A. O’Rourke, and J. P. McCabe Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre: A FIVE-YEAR ANALYSIS J Bone Joint Surg Br 2006; 88-B: 807-811 [Abstract] [Full text] [PDF]

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Author's reply:

Simon Roche   (23 October 2006)

Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre

D Sunderamoorthy   (7 August 2006)

Author's reply: 23 October 2006
Simon Roche, Specialist Registrar Orthopaedics Merlin Park Regional Hospital, Galway, Ireland Send letter to journal: Re: Author's reply: sroche1975{at}yahoo.co.uk Simon Roche	Sir, I found the comments and queries made by Mr Sunderamoorthy both incisive and relevant. Firstly, not all patients were screened on admission to the orthopaedic ward. The same criteria for screening were applied to both trauma and elective patients (as described in the Methods section). In doing so, the unit was adhering to national guidelines outlined by the Irish Department of Health in 1995. Incidentally, new national guidelines have been tabled for 2006. All elective cases are now screened at a pre-admission clinic setting. Due to limitations in the database, we are unable to compare outcomes in those who received vancomycin and were colonised on admission with those who did not receive vancomycin. Although we can identify those within this subgroup who did receive vancomycin, we are unable to state with certainty whether it was received before or after isolation of MRSA infection in the particular group who were positive on admission and subsequently developed MRSA infection. Not all of those who were positive on admission received antibiotic prophylaxis in addition to mupirocin ointment and 4% chlorhexidine body wash. Those undergoing implant-related surgery received cephalosporins pre-operatively. Vancomycin was administered to a small minority of this group where the risk of developing MRSA infection was deemed high (i.e. immunocompromise). New guidelines are now in place at our unit in relation to the administration of vancomycin. A pre-operative intravenous dose of 1 g is given to patients who are thought to be at high risk of contracting MRSA infection. This subgroup includes those colonised on admission, patients who are deemed immunocompromised, interhospital transfers without a negative screen, and also patients who are going to be nursed in close proximity to other cases of MRSA colonisation/infection due to problems with availability of beds. The patient cohorts identified by Mr Sunderamoorthy would appear to be worthy of further investigation in future prospective studies. S. ROCHE, Orthopaedic SpR, Merlin Park Regional Hospital, Galway, Ireland.
Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre 7 August 2006
D Sunderamoorthy, Registrar in Orthopaedics Leighton Hospital, Crewe, UK Send letter to journal: Re: Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre d.gray{at}jbjs.org.uk D Sunderamoorthy	Sir, I read the article by Roche et al in the June issue with great interest, as it emphasises the growing burden of MRSA in orthopaedic practice. In the methods section the authors state that "Routine screening is carried out on every patient previously colonised or infected with MRSA, transfers from nursing homes and long-stay residential institutions, frequently hospitalised patients and all national and international transfers." Does the above statement mean that only the above category patients were screened for MRSA on admission, or did it mean that all patients admitted to the orthopaedic wards were screened for MRSA on admission? There was no mention of the policy for MRSA screening in elective patients. 240 patients were colonised with MRSA, of which 173 were colonised with MRSA on admission. With regard to these latter patients, what was their antibiotic prophylaxis and did any of them receive vancomycin for their implant-related surgery? It would be nice to know the number of MRSA infections in this group and if there was any difference in the infection rate between those who received routine antibiotic prophylaxis and vancomycin. D. Sunderamoorthy, Registrar in Orthopaedics, Leighton Hospital, Crewe, UK.