J Bone Joint Surg Br -- eLetters for Walls et al., 90-B (3) 292-298

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R. J. Walls, S. J. Roche, A. O’Rourke, and J. P. McCabe
Surgical site infection with methicillin-resistant Staphylococcus aureus after primary total hip replacement
J Bone Joint Surg Br 2008; 90-B: 292-298 [Abstract] [Full text] [PDF]

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Author's reply:: Raymond J. Walls, Galway, Ireland (1 May 2008)

Surgical site infection with MRSA after primary total hip replacement: Benedict A Rogers, Nick J Little (15 April 2008)

Author's reply:: Raymond J. Walls (10 April 2008)

MRSA prosthetic joint infections: a word of caution for developing countries: Devdatta S Neogi, Dr Chandra Shekhar Yadav, Prof Shishir Rastogi (7 March 2008)

Author's reply: 1 May 2008

Raymond J. Walls,
Research Registrar
Merlin Park University Hospital,
Galway, Ireland
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Re: Author's reply:

raywalls1{at}hotmail.com Raymond J. Walls, et al.

Sir,
We would like to thank Mr Rogers for his interest in our paper and we welcome the opportunity to clarify some issues that have been raised.
Our hospital is a regional referral centre with many patients followed up at satellite institutions; unfortunately, the data was incomplete at these centres for the three cases mentioned, and so they were not included in this analysis.
It is correct to consider patient and operative risk factors separately; however, the emphasis of this paper was to review management of MRSA SSI when it actually occurs. We did mention that risk factors for MRSA colonisation and infection have already been reported, and we listed measures to aid reduction in infection rates. Patient factors include a past history of MRSA infection or colonisation, recent hospitilisation (<6 months), residence within long-term care facilities or in a community with high MRSA prevalence, presence of chronic wounds, presence of invasive medical devices, increasing age, malignancy and underlying disease.^1-6
In our series, four cases (27%) with MRSA present on admission were admitted electively from the community and none had been hospitalised prior to their surgery. We believe this serves as further evidence of the increasing prevalence of MRSA in the community.^1,7 A total of 11 of our cohort (73%) suffered concomitant medical conditions, with hypertension (55%) and rheumatoid arthritis (36%) the most common. As we reported, this information was obtained from a retrospective chart review and we did not routinely perform pre-operative assessments of nutritional status or severity of immunosuppression during this time. All patients were determined medically fit for primary hip arthroplasty. Five patients (33%) required steroid treatment for conditions including rheumatoid arthritis, polymyalgia rheumatica and asthma. If this immunosuppressive drug cannot be stopped in the peri-operative period we suggest that prophylactic vancomycin should be considered.
Surgical helmets or face masks with surgical hoods were worn in all cases depending on the consultant surgeons� preference, with no difference in infection rates determined. Drains were also inserted in all cases during this period and routinely removed at 48 hours. While there is not agreement in the literature on the use of drains following hip surgery, a recent study of 1207 hip arthroplasties did not find the use of drains to be associated with an increased incidence of periprosthetic infection.^8,9 Similar discrepancy exists regarding the relationship between operative time and post-operative infection.^9,10 Therefore, larger multicentre studies are needed to provide the statistical power for multivariate analysis to determine which individual factors increase the risk of MRSA SSI.
We consider the CDC guidelines, which have been widely accepted and used for reporting infection rates, to outline the criteria for surgical site infection clearly.^10-12 The paper highlighted by Mr Rogers only reported discrepancies with some components of the diagnostic criteria for superficial SSI and was performed by two clinicians and two nurses with varying levels of experience.¹³
We used inflammatory markers (ESR and CRP) to aid diagnosis and to monitor MRSA infection resolution. It can be difficult to differentiate early infected from non-infected cases as there is invariably a post-operative rise in both markers following hip surgery which may take several weeks to return to normal levels.¹⁴ MRSA is a highly virulent pathogen, reflected in our series with most SSI presenting early, and compounds the interpretation of high early post-operative levels. It is more appropriate to review serial tests as infected cases tend to have persistently elevated levels.¹⁴ Furthermore, conditions that may cause an abnormal rise of ESR and CRP include inflammatory disorders and malignancy¹⁵; such comorbidities affected six patients (out of 15) in our series. We therefore considered it inappropriate to report peak/pre-operative levels in this paper. However, we have discussed, where appropriate, normalisation of markers in relation to our management at all levels of SSI supporting successful MRSA eradication.
R.J. WALLS, MRCSI,
Research Registrar,
Merlin Park University Hospital,
Galway, Ireland.
1. Davis JS. Management of bone and joint infections due to Staphylococcus aureus. Intern Med J 2005;35(Suppl 2):79-96.
2. Roche SJ, Fitzgerald D, O�Rourke A, McCabe JP. Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre: a five-year analysis. J Bone Joint Surg [Br] 2006;88-B:807-811.
3. Samad A, Banerjee D, Carbarns N, Ghosh S. Prevalence of methicillin-resistant Staphylococcus aureus colonization in surgical patients, on admission to a Welsh hospital. J Hosp Infect 2002;51:43-6.
4. Nixon M, Jackson B, Varghese P, Jenkins D, Taylor G. Methicillin-resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J Bone Joint Surg [Br] 2006;88-B:812-7.
5. Giannoudis PV, Parker J, Wilcox MH. Methicillin-resistant Staphylococcus aureus in trauma and orthopaedic practice. J Bone Joint Surg [Br] 2005;87-B:749-54.
6. Tai CC, Nirvani AA, Holmes A, Hughes SP. Methicillin-resistant Staphylococcus aureus in orthopaedic surgery. Int Orthop 2004;28:32-5.
7. Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence and resurgence of methicillin-resistant Staphylococcus aureus as a public-health threat. Lancet 2006;368:874-85.
8. Walmsley PJ, Kelly MB, Hill RM, Brenkel I. A prospective, randomised, controlled trial of the use of drains in total hip arthroplasty. J Bone Joint Surg [Br] 2005;87-B:1397-401.
9. Dowsey MM, Choong PF. Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty. Clin Orthop Relat Res 2008:466:153-8.
10. Ridgeway S, Wilson J, Charlet A, et al. Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg [Br] 2005;87-B:844-50.
11. Lee J, Singletary R, Schmader K, et al. Surgical site infection in the elderly following orthopaedic surgery. Risk factors and outcomes. J Bone Joint Surg [Am] 2006;88-A:1705-712.
12. Morgan M, Black J, Bone F, et al. Clinician-led surgical site infection surveillance of orthopaedic procedures: a UK multi-centre pilot study. J Hosp Infect 2005;60:201-212.
13. Allami MK, Jamil W, Fourie B, Ashton V, Gregg PJ. Superficial incisional infection in arthroplasty of the lower limb. Interobserver reliability of the current diagnostic criteria. J Bone Joint Surg [Br] 2005;87-B:1267-71.
14. Okafor B, MacLellan G. Postoperative changes of erythrocyte sedimentation rate, plasma viscosity and C-reactive protein levels after hip surgery. Acta Orthop Belg 1998;64:52-6.
15. Austin MS, Ghanem E, Joshi A, Lindsay A, Parvizi J. A simple, cost-effective screening protocol to rule out periprosthetic infection. J Arthroplasty 2008;23:65-8.

Surgical site infection with MRSA after primary total hip replacement 15 April 2008

Benedict A Rogers,
Specialist Registrar
St Peter's Hospital, Chertsey, UK,
Nick J Little
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Re: Surgical site infection with MRSA after primary total hip replacement

benedictrogers{at}hotmail.com Benedict A Rogers, et al.

Sir,
We read this paper¹ with interest and would like to highlight some patient, surgical and methodological factors that were not detailed in this study.
Patient factors.
The methods report that the study sample was obtained from a series previously reported.² This original paper details that ��. of the 1790 primary total hip arthroplasties undertaken at the study hospital, 18 (1%) became infected with MRSA.� This recent paper reports just 15 patients. Were the remaining three lost to follow-up or excluded for some other reason?
Medical co-morbidities greatly affect surgical site infection rates. This study briefly lists the co-morbidities of the patient cohort, including rheumatoid arthritis, cancer and anaemia, three conditions in which there is a wide range of severity and inherent immunosuppressive potential.^3-6 Further, patients with these conditions will undoubtedly be on several medications that may have an immunosuppressive profile.⁷ More detail of both the severity of the co-morbidities and medication would be informative.
Nutritional status is known to be a significant predisposing factor to deep joint infection.^7-10 Similarly, obesity is another known risk factor of deep surgical infection¹¹ not reported in this study. Were any anthropometric, immunological or biochemical indicators � all known tools to assess nutritional status^7,9,10,12 - employed for the study?
Surgical factors.
There is no mention of length of operation. Longer surgical time is associated with an increased infection risk.¹³ There is conflicting evidence regarding the efficacy of surgical face masks and surgical hoods in reducing the bacteria contamination.^14-16 What did surgeons involved in this study wear?
Drains, despite being necessary in some particular clinical situations, are known to be associated with surgical site infection.¹⁷ Were drains routinely used for the surgery of these patients?
Methodological factors.
The components used to routinely diagnose surgical site infection are known to have a high inter-observer error.¹⁸ Was any assessment made of the inter-observer error in the diagnosis of superficial, deep or implant infection?
No results from the erythrocyte sedimentation rate or C-reactive protein serological investigations, mentioned in the methods, are documented. Both of these serological investigations have been shown to provide excellent diagnostic test information for establishing the presence or absence of infection following primary joint replacement surgery.^19,20
B.A. Rogers,
Specialist Registrar,
N.J. Little,
St Peter's Hospital,
Chertsey, UK.
1. Walls RJ, Roche SJ, O'Rourke A, McCabe JP. Surgical site infection with methicillin-resistant Staphylococcus aureus after primary total hip replacement. J Bone Joint Surg [Br] 2008;90-B:292-8.
2. Roche SJ, Fitzgerald D, O'Rourke A, McCabe JP. Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre: a five-year analysis. J Bone Joint Surg [Br] 2006;88-B:807-811.
3. Charnley J, Eftekhar N. Postoperative infection in total prosthetic replacement arthroplasty of the hip-joint. With special reference to the bacterial content of the air of the operating room. Br J Surg 1969;56:641-9.
4. Fitzgerald RH Jr, Nolan DR, Ilstrup DM, et al. Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg [Am] 1977;59-A:847-55.
5. Poss R, Thornhill TS, Ewald FC, et al. Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop 1984;182:117-26.
6. Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg [Am] 1990;72-A:878-83.
7. Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplasty 1991;6:321-5.
8. Gherini S, Vaughn BK, Lombardi AV Jr, Mallory TH. Delayed wound healing and nutritional deficiencies after total hip arthroplasty. Clin Orthop 1993;293:188-95.
9. Jensen JE, Jensen TG, Smith TK, Johnston DA, Dudrick SJ. Nutrition in orthopaedic surgery. J Bone Joint Surg [Am] 1982;64-A:1263-72.
10. Smith TK. Nutrition: its relationship to orthopedic infections. Orthop Clin North Am 1991;22:373-7.
11. Stern SH, Insall JN. Total knee arthroplasty in obese patients. J Bone Joint Surg [Am] 1990;72-A:1400-1404.
12. Doyon F, Evrard J, Mazas F. [Evaluation of therapeutic trials published apropos of antibiotic prophylaxis in orthopedic surgery]. Rev Chir Orthop Reparatrice Appar Mot 1989;75:72-6.(in French)
13. Yong KS, Kareem BA, Ruslan GN, Harwant S. Risk factors for infection in total hip replacement surgery at Hospital Kuala Lumpur. Med J Malaysia 2001;56SupplC:57-60.
14. Lindqvist C, Sl�tis P. Dental bacteremia--a neglected cause of arthroplasty infections? Three hip cases. Acta Orthop Scand 1985;56:506-508.
15. Mitchell NJ, Hunt S. Surgical face masks in modern operating rooms--a costly and unnecessary ritual? J Hosp Infect 1991;18:239-42.
16. Ritter MA, Eitzen H, French ML, Hart JB. The operating room environment as affected by people and the surgical face mask. Clin Orthop 1975;111:147-50.
17. Minnema B, Vearncombe M, Augustin A, Gollish J, Simor AE. Risk factors for surgical-site infection following primary total knee arthroplasty. Infect Control Hosp Epidemiol 2004;25:477-80.
18. Allami MK, Jamil W, Fourie B, Ashton V, Gregg PJ. Superficial incisional infection in arthroplasty of the lower limb. Interobserver reliability of the current diagnostic criteria. J Bone Joint Surg [Br] 2005;87-B:1267-71.
19. Greidanus NV, Masri BA, Garbuz DS, et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. A prospective evaluation. J Bone Joint Surg [Am] 2007;89-A:1409-1416.
20. Austin MS, Ghanem E, Joshi A, Lindsay A, Parvizi J. A simple, cost-effective screening protocol to rule out periprosthetic infection. J Arthroplasty 2008;23:65-8.

Author's reply: 10 April 2008

Raymond J. Walls,
Orthopaedic Research Registrar
Merlin Park University Hospital, Galway, Ireland
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Re: Author's reply:

raywalls1{at}hotmail.com Raymond J. Walls

Sir,
We would like to thank Doctor Neogi et al in India for their interest in our paper. We appreciate their concurrence of following guidelines for both antimicrobial and surgical management of MRSA infections. The worldwide variation of MRSA isolates requires regional consideration in its management and we agree that TB compounds this dilemma in developing countries.
The aim of the manuscript was to assess our management protocol in line with current strategies and provide recommendation accordingly; a comprehensive review of antimicrobial therapy was beyond the scope of our paper. We have advised the use of vancomycin with consideration of rifampicin and/or fuscidic acid as adjuvant therapy in deep SSI and implant infection. There is no doubt that the complexity in treating MRSA has been exacerbated through the emergence of community-acquired infections as well as vancomycin resistant strains. Consequently, there needs to be continuing development of agents effective against this multi-drug resistant organism with newer antibiotics such as daptomycin, tigecycline and quinupristin/dalfopristin now available.¹ Loffler and Macdougall² have also highlighted the potential role of older agents including clindamycin and doxycycline in the treatment of MRSA infection. However, the ultimate decision on medical therapy should be formed with appropriate microbiological services, taking into account the pathogen�s sensitivity, available antimicrobials, and local policy.
R.J. Walls,
Orthopaedic Research Registrar,
Merlin Park University Hospital,
Galway, Ireland.
1. Micek ST. Alternatives to vancomycin for the treatment of methicillin-resistant Staphylococcus aureus infections. Clin Infect Dis 2007;45:S184-90.
2. Loffler CA, Macdougall C. Update on prevalence and treatment of methicillin-resistant Staphylococcus aureus infections. Expert Rev Anti Infect Ther 2007;5:961-81.

MRSA prosthetic joint infections: a word of caution for developing countries 7 March 2008

Devdatta S Neogi,
M.S.(Ortho),DNB(Ortho Surg),MCh(Orth),MRCS,MNAMS
All India Institute of Medical Sciences, New Delhi, India,
Dr Chandra Shekhar Yadav, Prof Shishir Rastogi
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Re: MRSA prosthetic joint infections: a word of caution for developing countries

drdevdatt{at}gmail.com Devdatta S Neogi, et al.

Sir,
We read this paper with great interest in which the authors have highlighted the efforts involved in treatment of MRSA prosthetic joint infections and formulated a treatment protocol.
A prosthetic joint infection is a major source of morbidity and patients are subjected to prolonged antibiotic therapy. Antibiotic pressure is known to select mutants that can survive the adverse conditions and this has led to the emergence of drug-resistant bacteria. MRSA infection is being seen in as many as 0.5% of total hip replacements.¹ Lack of proper adherence to basic control measures such as hand washing and theatre discipline, and ignorance of existing guidelines regarding antibiotic use has contributed to MRSA resistance. Guidelines permit the use of a few drugs such as vancomycin and linezolid for use as monotherapy, but development of resistance to these agents is documented. Other drugs such as rifampicin and fusidic acid are never to be used as monotherapy.² Combination therapy may play a vital role in preventing the emergence of drug resistance.¹ MRSA has also shown development of resistance to rifampicin when this antibiotic was used in tuberculosis (TB) wards.³
One must exercise caution in the use of rifampicin in developing countries as TB is a public health problem in these countries with nine million people developing active TB every year and 1.7 million deaths annually.⁴ The prevalence of TB infection in all age groups in India is around 40% and the prevalence of all forms of TB disease is 5.05 million.⁵ Rifampicin is a very important drug in anti-tubercular chemotherapy. Efforts to �protect� rifampicin have been promulgated by organisations such as the World Health Organization and the International Union against Tuberculosis and Lung Disease, and the use of rifampicin for indications other than active TB and self-administration of rifampicin are strongly discouraged.^6,7
Minimising risk factors and following recommended antibiotic guidelines² and operative protocol¹ may decrease the morbidity of MRSA prosthetic joint infections and at the same time caution should be exercised in the use of rifampicin to lessen the likelihood of multidrug-resistant TB.
D.S. NEOGI, MS(Ortho), DNB(Orth Surg), MRCS(Ed),
C.S. YADAV, MS(Ortho),
S. RASTOGI, MS(Ortho),
All India Institute of Medical Sciences,
New Delhi, India.
1. Walls RJ, Roche SJ, O'Rourke A, McCabe JP. Surgical site infection with methicillin-resistant Staphylococcus aureus after primary total hip replacement. J Bone Joint Surg [Br] 2008;90-B:292-8.
2. Gemmell CG, Edwards DI, Fraise AP, et al. Guidelines for the prophylaxis and treatment of methicillin resistant Staphylococcus aureus (MRSA) infections in the UK. J Antimicrob Chemother 2006;57:589�608.
3. Sekiguchi J, Fujino T, Araake M, et al. Emergence of rifampicin resistance in methicillin-resistant Staphylococcus aureus in tuberculosis wards. J Infect Chemother 2006;12:47-50.
4. World Health Organization Tuberculosis fact sheets. http://www.who.int/mediacentre/factsheets/fs104/en/print.html. (Last accessed 08/02/2008).
5. Chakraborty AK. Epidemiology of tuberculosis: current status in India. Indian J Med Res 2004;120:248-76.
6. Espinal MA, Kim SJ, Suarez PG, et al. Standard short-course chemotherapy for drug-resistant tuberculosis: treatment outcomes in 6 countries. JAMA 2000;283:2537-45.
7. Rieder HL. Interventions for tuberculosis control and elimination. International Union Against Tuberculosis and Lung Disease (IUATLD), Paris 2002.

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Hip, Knee, Trauma, Upper limb, Foot & Ankle, Paediatrics, Oncology, Spine, Arthroplasty, General