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The hip fracture best practice tariff: early surgery and the implications for MRSA screening and antibiotic prophylaxis

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Abstract

In April 2010, the Department of Health 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 teicoplanin to patients with unknown MRSA status along with routine antimicrobial prophylaxis. The purpose of this study was to provide a safe and effective antimicrobial prophylaxis for hip fracture patients. We prospectively collected details of demographics 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. 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. 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.
1 23
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 [1014]. 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
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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 % [1517]. 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 [2226].
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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... In the case of beta-lactam type 1 (immunoglobulin E (IgE)-mediated) allergy, methicillinresistant S. aureus (MRSA) colonization or a high prevalence of nosocomial MRSA SSI, clindamycin, or a glycopeptide (vancomycin or teicoplanin) may be used [1,8,10]. Although cross-allergic reactions between penicillin and cephalosporins are uncommon, cephalosporins should not be used for surgical prophylaxis in patients with documented or presumed IgE-mediated penicillin allergy [1]. ...
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Background Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. Aim To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. Methods A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. Results A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). Conclusion These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.
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Aims Infection after surgery increases treatment costs and is associated with increased mortality. Hip fracture patients have historically had high rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization and surgical site infection (SSI). This paper reports the impact of routine MRSA screening and the “cleanyourhands” campaign on rates of MRSA SSI and patient outcome. Methods A total of 13,503 patients who presented with a hip fracture over 17 years formed the study population. Multivariable logistic regression was performed to determine risk factors for MRSA and SSI. Autoregressive integrated moving average (ARIMA) modelling adjusted for temporal trends in rates of MRSA. Kaplan-Meier estimators were generated to assess for changes in mortality. Results In all, 6,189 patients were identified before the introduction of screening and 7,314 in the post-screening cohort. MRSA infection fell from 69 cases to 15 in the post-screening cohort (p < 0.001). The ARIMA confirmed a significant reduction in MRSA SSI post-screening (p = 0.043) but no significant impact after hand hygiene alone (p = 0.121). Overall SSI fell (2.4% to 1.5%), however deep infection increased slightly (0.89% to 1.06%). ARIMA showed neither intervention affected overall SSI (“cleanyourhands” -0.172% (95% confidence interval (CI) -0.39% to 0.21); p = 0.122, screening -0.113% per year, (95% CI -0.34 to 0.12); p = 0.373). One-year mortality after deep SSI was unchanged after screening (50% vs 45%; p = 0.415). Only warfarinization (OR 3.616 (95% CI 1.366 to 9.569); p = 0.010) and screening (OR 0.189 (95% CI 0.086 to 0.414); p < 0.001) were significant covariables for developing MRSA SSI. Conclusion While screening and decolonization may reduce MRSA-associated SSI, the benefit to patient outcome remains unclear. Overall deep SSI remains an unsolved problem that has seen little improvement over time. Preventing other hospital-associated infections should not be forgotten in the fight against MRSA. Cite this article: Bone Joint J 2021;103-B(1):170–177.
Article
Objectives: To identify the methicillin-resistant Staphylococcus aureus (MRSA) carrier rate among surgical patients on an orthopaedic trauma service and to determine if screening is an effective tool for reducing post-operative MRSA infection in this population. Design: Prospective SETTING:: Level 1 trauma centerPatients/Participants: 248 patients with operatively managed orthopaedic trauma conditions during the study period. 203 patients (82%) had acute orthopaedic trauma injuries. 45 patients (18%) underwent surgery for a non-acute orthopaedic trauma condition, including 36 elective procedures and 9 procedures to address infection. Intervention: MRSA screening protocol, pre-operative antibiotics per protocol MAIN OUTCOME MEASUREMENTS:: MRSA carrier rate, overall infection rate, MRSA infection rate RESULTS:: Our screening captured 71% (175/248) of operatively treated orthopaedic trauma patients during the study period. The overall MRSA carrier rate was 3.4% (6/175). When separated by group, the acute orthopaedic trauma cohort had an MRSA carrier rate of 1.4% (2/143), and neither MRSA-positive patient developed a surgical site infection (SSI). Only one MRSA infection occurred in the acute orthopaedic trauma cohort. The non-acute group had a significantly higher MRSA carrier rate of 12.5% (4/32, p=0.01), and the elective group had the highest MRSA carrier rate of 15.4% (4/26, p<0.01). The odds ratio of MRSA colonization was 10.1 in the non-acute group (95% CI 1.87, 75.2) and 12.8 for true elective group (95% CI 2.36, 96.5) when compared to the acute orthopaedic trauma cohort. Conclusions: There was a low MRSA colonization rate (1.4%) among patients presenting to our institution for acute fracture care. Patients undergoing elective surgery for fracture-related conditions such as nonunion, malunion, revision surgery, or implant removal have a significantly higher MRSA carrier rate (15.4%) and therefore may benefit from MRSA screening. Our results do not support routine vancomycin administration for orthopaedic trauma patients whose MRSA status is not known at the time of surgery. Level of evidence: Prognostic Level I.
Article
Aims: The primary aim of this study was to determine whether orthopaedic trauma patients receive appropriate antibiotic prophylaxis keeping in view the results of their MRSA screening. The secondary aim was to analyse the risk of developing MRSA surgical site infection with and without appropriate antibiotic prophylaxis in those colonized with MRSA. Patients and methods: We reviewed 400 consecutive orthopaedic trauma patient episodes. Preoperative MRSA screening results, operative procedures, prophylactic antibiotics and postoperative course were explored. In addition to these consecutive patients, the hospital MRSA database over the previous 5 years identified 27 MRSA colonized acute trauma patients requiring surgery. Results: Of the 400 consecutive patient episodes, 395(98.7%) had MRSA screening performed on admission. However, in 236 (59.0%) cases, the results were not available before the surgery. Seven patient episodes (1.8%) had positive MRSA colonization. Analysis of 27 MRSA colonized patients revealed that 20(74%) patients did not have the screening results available before the surgery. Only 5(18.5%) received Teicoplanin and 22(81.4%) received cefuroxime for antibiotic prophylaxis before their surgery. Of those receiving cefuroxime, five (22.73%) patients developed postoperative MRSA surgical site infection (SSI) but none of those (0%) receiving Teicoplanin had MRSA SSI. The absolute risk reduction for SSI with Teicoplanin as antibiotic prophylaxis was 22.73% (CI=5.22%-40.24%) and NNT (Number Needed to Treat) was 5 (CI=2.5-19.2) CONCLUSION: Lack of available screening results before the surgery may lead to inadequate antibiotic prophylaxis increasing the risk of MRSA surgical site infection. Glycopeptide (e.g.Teicoplanin) prophylaxis should be considered when there is history of MRSA colonization or MRSA screening results are not available before the surgery.
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Purpose of the review: Recent health laws have shifted from the traditional fee-for-service model toward a pay-for-performance model. In this changing climate, it is imperative that a provider understands these changes and recognizes the importance of health services research on medicine. Recent findings: Increasing the value of care by improving quality and decreasing cost has been the focus of several projects. Preventing complications may be an effective way to increase value. Patient risk stratification is a modifiable variable that will allow for improved patient selection. This in turn may reduce adverse events, thereby lessening the economic burden of complications, increased length of stay, and hospital readmission. Providers must partner with their hospitals to align their goals and maximize quality and efficiency in order to decrease costs.
Article
Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk. This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics. Cite this article: Bone Joint J 2016;98-B:1014–19.
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Antimicrobial prophylaxis remains the most powerful tool used to reduce infection rates in orthopaedics but the choice of antibiotic is complex. The aim of this study was to examine trends in antimicrobial prophylaxis in orthopaedic surgery involving the insertion of metalwork between 2005 and 2011. Two questionnaires (one in 2008 and one in 2011) were sent to all National Health Service trusts in the UK using the Freedom of Information Act. In total, 87% of trusts that perform orthopaedic surgery responded. The use of cefuroxime more than halved between 2005 and 2011 from 80% to 36% and 78% to 26% in elective surgery and trauma surgery respectively. Combination therapy with flucloxacillin and gentamicin rose from 1% to 32% in elective and 1% to 34% in trauma surgery. Other increasingly popular regimes include teicoplanin and gentamicin (1% to 10% in elective, 1% to 6% in trauma) and co-amoxiclav (3% to 8% in elective, 4% to 14% in trauma). The majority of changes occurred between 2008 and 2010. Over half (56%) of the trusts stated that Clostridium difficile was the main reason for changing regimes. In 2008 a systematic review involving 11,343 participants failed to show a difference in surgical site infections when comparing different antimicrobial prophylaxis regimes in orthopaedic surgery. Concerns over C difficile and methicillin resistant Staphylococcus aureus have influenced antimicrobial regimes in both trauma and elective surgery. Teicoplanin would be an appropriate choice for antimicrobial prophylaxis in both trauma and elective units but this is not reflected in its current level of popularity.
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Since its isolation, Methicillin-resistant Staphlococcus aureus (MRSA) has become a major cause of hospital acquired infection (HAI), adverse patient outcome and overall resource utilisation. It is endemic in Scotland and widespread in Western hospitals. MRSA has been the subject of widespread media interest--a manifestation of concerns about sterile surgical techniques and hospital cleanliness. This study aimed to investigate patient outcome of MRSA infections over the last decade at a major orthopaedic trauma centre. The objective was to establish the association of variables, such as patient age and inpatient residence, against patient outcome, in order to quantify significant relationships; facilitating the evaluation of management strategies with an aim to improving patient outcomes and targeting high-risk procedures. This is a retrospective study of the rates and outcomes of MRSA infection in orthopaedic trauma at the Royal Infirmary of Edinburgh. Data was collated using SPSS 14.0 for Windows(R). Shapiro-Wilkes testing was performed to investigate the normality of continuous data sets (e.g: age). Data was analysed using both Chi-Squared and Fisher's exact tests (in cases of expected values under 5) This study found significant associations between adverse patient outcome (persistent deep infection, osteomyelitis, the necessity for revision surgery, amputation and mortality) and the following patient variables: Length of inpatient stay, immuno-compromise, pre-admission residence in an institutional setting (such as a residential nursing home) and the number of antibiotics used in patient care. Despite 63% of all infections sampled resulting from proximal femoral fractures, no association between patient outcome and site of infection or diagnosis was found. Somewhat surprisingly, the relationship between age and outcome of infection was not proved to be significant, contradicting previous studies suggesting a statistical association. Antibiotic prophylaxis, previously identified as a factor in reducing overall incidence of MRSA infection, was not found to be significantly associated with outcome. Early identification of high-risk patients as identified by this study could lead to more judicious use of therapeutic antibiotics and reductions in adverse outcome, as well as socioeconomic cost. These results could assist in more accurate risk stratification based on evidence based evaluation of the significance of the risk factors investigated.
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The objective of this study was to determine the effectiveness of screening and successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in elective orthopaedic patients on the subsequent risk of developing a surgical site infection (SSI) with MRSA. We screened 5933 elective orthopaedic in-patients for MRSA at pre-operative assessment. Of these, 108 (1.8%) were colonised with MRSA and 90 subsequently underwent surgery. Despite effective eradication therapy, six of these (6.7%) had an SSI within one year of surgery. Among these infections, deep sepsis occurred in four cases (4.4%) and superficial infection in two (2.2%). The responsible organism in four of the six cases was MRSA. Further analysis showed that patients undergoing surgery for joint replacement of the lower limb were at significantly increased risk of an SSI if previously colonised with MRSA. We conclude that previously MRSA-colonised patients undergoing elective surgery are at an increased risk of an SSI compared with other elective patients, and that this risk is significant for those undergoing joint replacement of the lower limb. Furthermore, when an infection occurs, it is likely to be due to MRSA.
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In a prospective study we assessed 440 patients, sequentially admitted to the trauma unit with hip fracture. Of the 403 who had a swab on admission, 5.2% (21/403) were found to be colonised with MRSA. Fifty two percent of MRSA colonised patients were admitted from their own home, 29% from residential homes and 19% from nursing homes. MRSA colonisation was found in 3.6% of patients admitted from their own home, 10.9% of residential home patients, and 17.4% of nursing home patients. A high proportion (80.9%) of colonised patients had been admitted to a hospital within the previous one year, and the high prevalence of previous hospitalisation among people from institutional care may explain the higher rates of MRSA carriage among these individuals. When a patient gives a history of hospitalisation within the previous year, it is clearly sensible to consider the use of an agent such as teicoplanin for perioperative prophylaxis.
Article
Background: Hip fracture is a common injury with associated high mortality. Recent drives by the Department of Health have sought to prioritise these patients' care. In April 2010, the Best Practice Tariff was introduced in England and Wales. This offers financial incentives to institutions that provide holistic care and surgery within 36h for hip fracture patients. The England and Wales National Institute for Health and Clinical Excellence (NICE) published its first guidance on hip fracture management in June 2011, and emphasised the need for surgery on the day or day after admission. In spite of the emphasis placed on this injury, the predictors of in-hospital mortality remain ill-defined. In particular the effect of the timing of surgery remains contentious. Objective: To address the issues raised by NICE around surgical timing and examine whether surgery before a 36h watershed improves survival. In addition, to examine survival outcomes for each 12h watershed following admission. Materials and methods: Prospectively collected data on 2056 patients presenting to our unit with hip fractures between February 2008 and May 2011 were retrospectively reviewed. Multivariate regression analysis was used to correct for confounders, and so determine the effect of various parameters on in-patient mortality. Results: Age (p<0.0001), male-gender (p<0.0001), source of admission (p<0.05), ASA-grade (p<0.0001) and delay of surgery (p<0.01) were associated with an increased risk of in-hospital mortality. The adjusted odds of in-hospital mortality were 1.58 (p<0.05) times higher in those undergoing surgery after 36h compared to surgery before this time. Early surgery (within 24h) resulted in reduced in-hospital mortality when compared to the 36h watershed. Similarly ultra-early surgery (within 12h) was even better still (adjusted odds ratio 3.9 p<0.05). Conclusions: Expeditious surgery is associated with improved patient survival. Other predictors of in-hospital mortality include age, gender, in-hospital fracture and ASA-grade. Ultra-early surgery (within 12h) reduces risk of in-hospital mortality.
Article
 A randomized multicenter study was carried out in 12 centers in Italy to compare administration of a single dose of teicoplanin (400 mg i.v. bolus at time of anesthesia) versus that of five doses of cefazolin over a 24-h period (2 g at induction of anesthesia and 1 g every 6 h postoperatively, i.v. bolus) as antimicrobial prophylaxis in patients undergoing hip or knee arthroplasty. Of 860 patients enrolled, 427 received teicoplanin and 433 cefazolin. A total of 846 patients (422 teicoplanin and 424 cefazolin) were evaluable for safety and 826 patients for efficacy. Six patients (1.5%) in the teicoplanin group and seven patients (1.7%) in the cefazolin group developed a surgical wound infection during their postoperative hospital stay: this difference was not significant. Proven or suspected infections involving other body systems occurred in 114 patients (57 in each group). Seven hundred ninety-two patients completed a 3-month evaluation and 738 patients a 12-month evaluation; the success rates in evaluable patients at these observation times were 99.2% and 99.7% for teicoplanin and 99.2% and 99.7% for cefazolin, respectively. Adverse events occurred in three (0.7%) teicoplanin patients and nine (2.1%) cefazolin patients (P=0.083). A single preoperative dose of teicoplanin ensures adequate surgical antisepsis, with results comparable to a standard multiple-dose regimen of cefazolin.
Article
Background: Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection prevention and control strategies are important in preventing and controlling MRSA transmission. Objectives: To determine the effects of infection prevention and control strategies for preventing the transmission of MRSA in nursing homes for older people. Search methods: In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Database of Abstracts of Reviews of Effects (DARE, The Cochrane Library), Ovid MEDLINE, OVID MEDLINE (In-process and Other Non-Indexed Citations), Ovid EMBASE, EBSCO CINAHL, Web of Science and the Health Technology Assessment (HTA) website. Research in progress was sought through Current Clinical Trials, Gateway to Reseach, and HSRProj (Health Services Research Projects in Progress). Selection criteria: All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection prevention and control interventions in nursing homes for older people were eligible for inclusion. Data collection and analysis: Two review authors independently reviewed the results of the searches. Another review author appraised identified papers and undertook data extraction which was checked by a second review author. Main results: For this third update only one study was identified, therefore it was not possible to undertake a meta-analysis. A cluster randomised controlled trial in 32 nursing homes evaluated the effect of an infection control education and training programme on MRSA prevalence. The primary outcome was MRSA prevalence in residents and staff, and a change in infection control audit scores which measured adherence to infection control standards. At the end of the 12 month study, there was no change in MRSA prevalence between intervention and control sites, while mean infection control audit scores were significantly higher in the intervention homes compared with control homes. Authors' conclusions: There is a lack of research evaluating the effects on MRSA transmission of infection prevention and control strategies in nursing homes. Rigorous studies should be conducted in nursing homes, involving residents and staff to test interventions that have been specifically designed for this unique environment.
Article
Clin Microbiol Infect 2010; 16: 1747–1753 Policy-makers have recommended universal screening to reduce nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Risk profiling of MRSA carriers and rapid PCR tests are now available, yet cost-effectiveness data are limited. The present study assessed the cost-effectiveness of universal PCR screening on admission to surgery. A decision analysis model from the hospital perspective compared costs and the probability of any MRSA infection across three strategies: (i) PCR screening; (ii) screening for risk factors (prior hospitalization or antibiotic use) combined with pre-emptive isolation and contact precautions pending chromogenic agar results; and (iii) no screening. Clinical data were taken from studies at a Swiss teaching hospital as well as from published literature. Costs were derived from hospital accounting systems. Compared to no screening, the PCR strategy resulted in higher costs (CHF 10 503 vs. 10 358) but a lower infection probability (0.0041 vs. 0.0088), producing a base-case incremental cost-effectiveness ratio of CHF 30 784 per MRSA infection avoided. The risk factor strategy was more costly yet less effective than PCR, although, after varying epidemiologic inputs, the costs and effects of both screening strategies were similar. Sensitivity analyses suggested that on-admission prevalence of MRSA carriage predicts cost-effectiveness, alongside the probability of cross-transmission, and the costs of MRSA infection, screening and contact precautions. Although reducing the risk of MRSA infection, universal PCR screening is not strongly cost-effective at our centre. However, local epidemiology plays a critical role. Settings with a higher prevalence of MRSA colonization may find universal screening cost-effective and, in some cases, cost-saving.
Article
A controlled prospective trial to compare the efficacy of the antibiotics cephaloridine and flucloxacillin in preventing infection after total hip replacement was conducted at three hospitals. The antibiotic regimens began before surgery, cephaloridine being continued for 12 hours and flucloxacillin for 14 days afterwards. Over an 18-month period 297 patients undergoing a total of 310 hip replacements were entered into the trial and randomly allocated to one of the regimens. The follow-up period ranged from one to two and a half years. All operations were performed in conventional operating theatres; at two of the hospitals these were also used by various other surgical disciplines. Four patients developed deep infection, two having received the cephaloridine and two the flucloxacillin regimen. The overall rate of deep infection was therefore 1.3%. Thus three doses of cephaloridine proved to be as effective as a two-week regimen of flucloxacillin. Giving a prophylactic systemic antibiotic reduced the incidence of infection to a level comparable with that obtained in ultra-clean-air operating enclosures.