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European Journal of Orthopaedic
Surgery & Traumatology
ISSN 1633-8065
Eur J Orthop Surg Traumatol
DOI 10.1007/s00590-014-1448-6
The hip fracture best practice tariff: early
surgery and the implications for MRSA
screening and antibiotic prophylaxis
David J.Bryson, Abhinav Gulihar,
Randeep S.Aujla & Grahame J.S.Taylor
1 23
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ORIGINAL ARTICLE
The hip fracture best practice tariff: early surgery
and the implications for MRSA screening and antibiotic
prophylaxis
David J. Bryson •Abhinav Gulihar •
Randeep S. Aujla •Grahame J. S. Taylor
Received: 8 November 2013 / Accepted: 23 March 2014
Springer-Verlag France 2014
Abstract
Background In April 2010, the DepartmentofHealth
introduced the hip fracture best practice. Among the clinical
criteria required to earn remuneration is surgery within 36 h of
admission. However, early surgery may mean that methicillin-
resistant Staphylococcus aureus (MRSA) colonisation status is
not known before surgery, and therefore, appropriate antibiotic
prophylaxis may not be administered. In view of this, our
department’s policy is to administer an additional dose of tei-
coplanin to patients with unknown MRSA status along with
routine antimicrobial prophylaxis.
Aim The purpose of this study was to provide a safe and
effective antimicrobial prophylaxis for hip fracture
patients.
Methods We prospectively collected details of demo-
graphics and antimicrobial prophylaxis for all patients
admitted with a hip fracture in November 2011. This was
repeated in February 2012 after an educational and
advertising drive to improve compliance with departmental
antimicrobial policy. Microbiology results were obtained
from the hospital microbiology database. A cost-benefit
analysis was undertaken to assess this regime.
Results A total of 144 hip fracture patients were admitted
during the 2 months. The average admission to surgery
time was 32 h, and the average MRSA swab processing
time was 35 h. 86 % of patients reached theatre with
unknown MRSA status. Compliance with the departmental
antimicrobial policy improved from 25 % in November
2011 to 76 % in February 2012. Potential savings of
£40,000 were calculated.
Conclusion With best practice tariff resulting in 86 % of
patients reaching theatre with unknown MRSA status, we
advocate an additional single dose of teicoplanin to cover
against possible MRSA colonisation.
Keywords Hip fracture Methicillin-resistant
Staphylococcus aureus (MRSA) Teicoplanin
Antimicrobial prophylaxis
Introduction
The hip fracture best practice tariff was introduced in April
2010 to encourage hospitals to provide best practice.
Among the clinical standards required to earn remuneration
is operative intervention within 36 h of admission [1].
Surgery performed within this timeframe has been shown
to confer significant survival advantage [2] for 1-month
and 1-year mortality compared to patients whose surgery
was delayed for more than 4 days [3,4]. However, early
surgery may mean that methicillin-resistant Staphylococ-
cus aureus (MRSA) status is not known before surgery and,
as a consequence, appropriate antibiotic prophylaxis may
not be administered.
Despite the widespread introduction of stringent infec-
tion control measures, MRSA remains a serious nosoco-
mial pathogen in hospital and institutional settings [5,6].
D. J. Bryson (&)
Department of Orthopaedic Surgery, Kings Mill Hospital,
Mansfield Road, Sutton-In-Ashfield,
Nottinghamshire NG17 4JL, UK
e-mail: Davidjbryson@hotmail.com
A. Gulihar
Department of Orthopaedics, William Harvey Hospital,
Ashford, UK
R. S. Aujla G. J. S. Taylor
Department of Orthopaedics, University Hospitals of Leicester
NHS Trust, Leicester Royal Infirmary, Infirmary Square,
Leicester LE1 5WW, UK
123
Eur J Orthop Surg Traumatol
DOI 10.1007/s00590-014-1448-6
Author's personal copy
The overall incidence of MRSA colonisation on trauma
wards at our institution has previously been reported at
3.8 % [7]. Studies have shown the incidence of MRSA
colonisation amongst hip fracture patients to be greater
than 5 % [8]. Up to a quarter of patients colonised with
MRSA will develop MRSA infection and hip fracture,
patients with MRSA infection have a mortality rate 2.7
times greater than matched MRSA-negative controls [7,9].
Prophylactic antibiotics administered on induction have
been shown to reduce the incidence of wound infection
after hip arthroplasty surgery, including hip fracture sur-
gery [10–14]. Until October 2011, patients in our institu-
tion undergoing hip fracture surgery received 1.2 g of
intravenous (IV) co-amoxiclav on induction and two
600 mg post-operative doses. Penicillin-allergic patients
received single doses of 400 mg IV teicoplanin and
120 mg IV gentamicin. Following an internal audit show-
ing that more than 50 % of trauma patients arrived in
theatre with unknown MRSA status, a new antimicrobial
policy was introduced. Patients with unknown MRSA
status were given additional teicoplanin prophylaxis (one
dose 400 mg IV on induction).
The purpose of this study was to provide safe and effective
antimicrobial prophylaxis for hip fracture patients. This
involved several objectives. To assess (1) the proportion of
hip fracture patients who underwent operative intervention
before their MRSA status was known, (2) average time from
admission to surgery, (3) MRSA swab processing time, (4)
current incidence of MRSA colonisation amongst patients
admitted with a hip fracture, (5) compliance with the new
policy and (6) the cost-benefit of the changes.
Methods
We prospectively collected data for all patients with a hip
fracture admitted to our department throughout November
2011 and repeated this in February 2012, following an
advertising and educational programme to improve com-
pliance with the new antibiotic policy. This included
announcements on the hospital intranet, posters displayed
in all orthopaedic theatres and associated anaesthetic
facilities, emails, and verbal notification for members of
the orthopaedic and anaesthetic teams.
Data on patient demographics, date and time of admis-
sion, and date and time of surgery were obtained from the
hospital National Hip Fracture Database (NHFD). Admis-
sion was defined as arrival in the Emergency Department
or date and time of diagnosis for in-patients. Details on the
type, dose, and timing of prophylactic antimicrobials were
obtained from anaesthetic and drug charts. The microbi-
ology database provided dates and times for receipt of
swabs and MRSA result availability.
Taking data from the hospital NHFD and microbiology
database, we calculated the incidence of MRSA colonisa-
tion for all hip fracture admissions for the year 2011.
Results
November 2011
There were 83 patients with a proximal femur fracture.
Their mean age was 81 years (range 40–100 years); 62
were female and 21 male. Operative intervention was
undertaken in 81 patients, and two were treated conserva-
tively. Of those having non-operative treatment, one was
paraplegic and bed-bound, and the other had terminal
malignancy.
The time between admission and surgery was mean 32 h
(median 25 h, range 9–250 h). The time to process the
MRSA swabs was mean 33 h (median 32, range 22–64 h).
Routine MRSA screening did not occur for 3 patients. The
results of MRSA screening swabs were not available for 71
patients at the time of surgery (88 %). Two of these
patients were subsequently shown to be MRSA-positive.
Eleven patients (14 %) were penicillin allergic. Overall
compliance with the antimicrobial prophylaxis policy was
25 %.
February 2012
There were 61 patients with proximal femoral fracture.
Their mean age was 81 years (range 33–98 years); 48 were
female and 13 male. The time between admission and sur-
gery was mean 32 h (median 25 h and range 3–100 h). The
time to process MRSA swabs was 37 h (median 25 h, range
14–91 h). Routine MRSA screening did not occur for two
patients. None of the patients were colonised with MRSA.
The results of MRSA screening swabs were not available
for 51 patients at the time of surgery (84 %). Seven patients
(12 %) were penicillin allergic. Overall compliance with
the new policy on antimicrobial prophylaxis was 76 %.
MRSA colonisation was identified in 15 of 811 (1.8 %)
of patients admitted with a hip fracture in 2011.
Discussion
This study confirms that the financial incentives of the best
practice tariff have resulted in time to surgery frequently
outpacing MRSA screening. The average time from
admission to surgery was 32 h, while the average time for
MRSA swab processing was 35 h. As a consequence, 86 %
of patients arrived in theatre before their MRSA status was
known.
Eur J Orthop Surg Traumatol
123
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Patients with a hip fracture are considered to be at high
risk for MRSA colonisation, and therefore MRSA infec-
tion, as many will have been hospitalised before or reside
in nursing or residential homes where the prevalence of
MRSA colonisation has been reported between 4.7 and
22 % [15–17]. In a prospective review of 440 hip fracture
patients, 403 of whom were swabbed for MRSA on
admission, Thyagarajan et al. [8] reported the incidence of
MRSA colonisation at 5.2 % with 80.9 % of the colonised
patients having been admitted to hospital within the pre-
vious year.
Prophylactic antibiotics, administered at induction, have
been shown capable of reducing the incidence of surgical
site infection (SSI). A 2004 metanalysis revealed that
antibiotic prophylaxis reduced the incidence of superficial
and deep wound infection in hip fracture patients from
10.4 % in a placebo group to 5.3 % in those a receiving
treatment [13]. In 2005, the Health Protection Agency
reported the risk of surgical site infection (SSI) following
hip hemiarthroplasty at 4.97 % with MRSA isolates
responsible for 40 % of SSIs [18].
In patients colonised or infected with MRSA, glyco-
peptide therapy with vancomycin or teicoplanin is recom-
mended [19]. Vancomycin may offer superior treatment
with more rapid killing due to lower protein binding, but
this is tempered by a greater side effect profile such as
nephrotoxicity [20]. Also, bolus administration has been
reported to cause anaphylactoid reactions such as signifi-
cant hypotension and Red Man Syndrome, and adminis-
tration is advised as an infusion over a minimum of 60 min
[15,21,22]. However, in practice, this administration is
difficult to deliver effectively. The results of a previous
internal audit in 2010, when vancomycin was prophylaxis
for penicillin-allergic patients, identified 100 % failure of
correct administration with 30 % of patients never receiv-
ing any prophylaxis.
Teicoplanin is effective against staphylococci including
methicillin-sensitive and methicillin-resistant strains, can
be administered as a bolus at anaesthetic induction, and
shows good penetration into bone [20,21,23]. It has a long
half-life allowing single-dose administration, low toxicity
and has been shown to be equally effective as standard
prophylactic regimes using cephalosporins [22–26].
As a consequence of the above, we changed prophylaxis
to the current use of teicoplanin by bolus at induction.
However, compliance with teicoplanin, although better
than previously, only achieved 25 %. Following a targeted
educational drive to the department involving emails,
posters, and announcements on the hospital intranet, this
improved the compliance to 76 %.
In those who develop deep MRSA infection, the average
length of hospital admission has been reported at more that
100 days with pre-discharge mortality as high as 48 % [27].
The economic consequences of MRSA infection are also
significant. The cost of treating a single MRSA hip infection
has been estimated between £13,000 and £38,000 [7,27].
Early surgery may mean that MRSA status is not known
before surgery and appropriate antibiotic prophylaxis may
not be administered. It can take 24 h to culture swabs on
Baird-Parker selective medium [7], but the results of this
study suggest that the process of MRSA screening invariably
takes longer than this—the average MRSA swab processing
time during this study was 35 h. This is in keeping with
previous studies showing that culture on chromogenic agar
took 28 h [28], with very few culture techniques showing
MRSA positivity at 24 h [29]. One possible alternative is
polymerase chain reaction (PCR) technology which is both
rapid and highly sensitive [30] and is considered capable of
identifying MRSA with 96 % sensitivity and a 5 % inci-
dence of false positives [31] with a 24-h turnaround [28,31].
The other option, as adopted by our hospital, is to assume that
patients of unknown MRSA status are positive. A 2010 cost-
based analysis placed the cost of a single dose of teicoplanin
at approximately £6. The cost of PCR MRSA testing is
approximately £26 per test (Cepheid UK, High Wycombe,
UK). However, this does not include the cost of subsequent
sample culture in those patients found to be MRSA-positive.
This would be required to determine susceptibility of the
MRSA to antibiotics including vancomycin and mupirocin.
Moreover, as Ritchie et al. [31] point out, in routine clinical
practice where samples are compiled in batches prior to
processing, the potentially expeditious processing via PCR
techniques would be lost and would not confer a time
advantage over chromogenic agar testing.
We recognise that this study has some limitations and
implications. The numbers in this study are small, but taken
over two discrete 1-month intervals, we believe that they are
reflective of the hip fracture population. We did not follow our
patients beyond 24-h post-surgery and the administration of
post-operative antibiotics and are not able to commenton post-
operative complications such as infection.
The incidence of MRSA colonisation amongst hip
fracture admissions in this study was 1.8 %. This repre-
sents a reduction from a previously reported incidence of
5.8 % in our department in 2006 [7]. This reduction is
probably the result of widespread infection prevention
measures in the hospital and community over the past
decade but repeat analysis is required to see if this trend is
maintained.
The reduction in the incidence of MRSA colonisation
necessarily raises the question of the appropriateness of
routine administration of teicoplanin to patients of unknown
MRSA status. Vancomycin-resistant Staphylococcus aur-
eus and enterococci have been widely reported. More
recently, MRSA strains with decreased teicoplanin sus-
ceptibility have been identified [32], prompting some
Eur J Orthop Surg Traumatol
123
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authors to express concern the general use of glycopeptides
prophylaxis on the grounds that it may promote the evolu-
tion of antimicrobial resistance to these agents [19,22,33,
34]. Another option, as advocated by Thyagarajan et al. [8],
is to utilise teicoplanin prophylaxis for patients with a his-
tory of previous hospital admission (within the previous
year) and those living in care homes, which will reportedly
identify 85 % of MRSA carriers. However, as the results of
our study show, even when teicoplanin is the default anti-
microbial prophylaxis, compliance was 76 %. Asking
members of the orthopaedic and anaesthetic teams to risk-
stratify patients for antibiotic prophylaxis on the basis of
residential status and previous admission history may lead
to further reduction in compliance with the potential for
insufficient antimicrobial prophylaxis.
On balance, when the health and economic implications
of MRSA infection are considered, we believe that the
argument for treating patients whose MRSA status is
unknown as positive is strengthened. Based on MRSA
incidence, risk of infection, and the costs of teicoplanin, the
cost–benefit relationship of prophylactic teicoplanin is
demonstrated below:
MRSA infection and antibiotics
•811 hip fractures/year 91.8 % MRSA colonisa-
tion =15 MRSA colonised patients
•Up to of these 15 will develop infection [9]=4
MRSA infections
•Antibiotic prophylaxis decreases infection risk by
threefold in joint arthroplasty procedures [35]
•Thus, three infections prevented at est. cost of £13,792
[7]=£41, 376 saved
Cost of teicoplanin
•811 hip fractures/year 988 % arriving in theatre
unknown MRSA status =714
•£6 for dose teicoplanin 9714 =£4,284
Potential annual saving of administering teicoplanin
to patients of unknown MRSA status
•£41,376-£4,284 =£37,092
Conclusion
With best practice tariff resulting in 86 % of patients
reaching theatre with unknown MRSA status, we advocate
an additional single dose of teicoplanin to cover against
possible MRSA colonisation. This is supported by a cost-
benefit analysis.
Conflict of interest None.
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