Abstract
Background
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.
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 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.
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.
Similar content being viewed by others
References
Department of Health (2010) Best Practice Tariff. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHSFinancialReforms/DH_105080. Accessed 31 October 2012
Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG (2013) Early and ultra-early surgery in hip fracture patients improves survival. Injury 44:726–729
Novack V, Jotkowitz, Etzion O, Porath A (2007) Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care 19:170–176
Moran CG, Wenn RT, Sikand M, Taylor AM (2005) Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am 87:483–489
Hughes C, Smith M, Tunney M, Bradley MC (2011) Infection control strategies for preventing transmission of methicillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people. Cochrane Database Syst Rev 12:CD006354
Eseonu KC, Middleton SD, Eseonu CC (2011) A retrospective study of risk factors for poor outcomes in methicillin-resistant Staphylococcus aureus (MRSA) infection in surgical patients. J Orthop Surg Res 6:25
Nixon M, Jackson B, Varghese P, Jenkins D, Taylor G (2006) Methicillin-resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J Bone Joint Surg Br 88:812–817
Thyagarajn D, Sunderamoorthy D, Haridas S, Beck S, Praven P, Johansen A (2009) MRSA colonisation in patients admitted with hip fracture: implications for prevention of surgical site infection. Acta Orthop Belg 75:252–257
Davis KA, Stewart JJ, Crouch HK, Florez CE, Hospenthal DR (2004) Methicillin-resistant Staphylococcus aureus (MRSA) nares colonization at hospital admission and its effects on subsequent MRSA infection. Clin Infect Dis 39:776–782
Hill C, Flamant R, Mazas F, Evard J (1981) Prophylactic cefazolin versus placebo in total hip replacement. Report of a multicentre double-blind randomised trial. Lancet 1:795–796
van Kasteren ME, Mannien J, Ott A, Kulberg BJ, de Boer AS, Gyssens IC (2007) Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis 44:921–927
Pollard JP, Hughes SP, Scott JE, Evans MJ, Benson MK (1979) Antibiotic prophylaxis in total hip replacement. Br Med J 1:707–709
Southwell-Keely JP, Russo RR, March L, Cumming R, Cameron I, Brnabic AJ (2004) Antibiotic prophylaxis in hip fracture surgery: a metaanalysis. Clin Orthop Relat Res 419:179–184
Boyd RJ, Burke JF, Colton T (1973) A double-blind clinical trial of prophylactic antibiotics in hip fractures. J Bone Joint Surg Am 55:1251–1256
Soriano A, Popescu D, Garcia S, Bori G, Martinez JA, Balasso V, Marco F, Almela M, Mensa J (2006) Usefulness of teicoplanin for preventing methicillin-resistant Staphylococcus aureus infections in orthopaedic surgery. Eur J Clin Microbiol Infect Dis 24:35–38
Cox RA, Bowie PE (1999) Methicillin-resistant Staphylococcus aureus colonization: a prevalence study in Northamptonshire. J Hosp Infect 43:115–122
Barr B, Wilcox MH, Brady A, Parnell P, Darby B, Tompkins D (2007) Prevalence of methicillin-resistant Staphylococcus aureus colonization among older residents of care homes in the United Kingdom. Infect Control Hosp Epidemiol 28:853–859
Ridgeway S, Wilson J, Charlet A, Kafatos G, Pearson A, Coello R (2005) Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg Br 87:844–850
Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE (2006) Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. J Antimicrob Chemother 57:589–608
Darley ES, MacGowan AP (2004) Antibiotic treatment of gram-positive bone and joint infections. J Antimicrob Chemother 53:928–935
Joint Formulary Committee (2008) British national formulary, 55th edn. BMJ Group and Pharmaceutical Press, London
Periti P, Mini E, Mosconi G (1998) Antimicrobial prophylaxis in orthopaedic surgery: the role of teicoplanin. J Antimicrob Chemother 41:329–340
Suter F, Avai A, Fusco U, Gerundini M, Capriolo S, Maggiolo F (1994) Teicoplanin versus cefamandole in the prevention of infection in total hip replacement. Eur J Clin Microbiol Infect Dis 13:793–796
Vardakas KZ, Soteriades ES, Chrysanthopoulou SA, Papagelopoulos PJ, Falagas ME (2005) Perioperative anti-infective prophylaxis with teicoplanin compared to cephalosporins in orthopaedic and vascular surgery involving prosthetic material. Clin Microbiol Infect 11:775–777
Periti P, Stringa G, Mini E (1999) Comparative multicenter trial of teicoplanin versus cefazolin for antimicrobial prophylaxis in prosthetic joint implant surgery. Italian study group for antimicrobial prophylaxis in orthopaedic surgery. Eur J Clin Microbiol Infect Dis 18:113–119
Wall R, Klenerman L, McCullough C, Fyfe I (1988) A comparison of teicoplanin and cefuroxime as prophylaxis for orthopaedic implant surgery: a preliminary report. J Antimicrob Chemother 21:141–146
Edwards C, Counsell A, Boulton C, Moran CG (2008) Early infection after hip fracture surgery: risk factors, costs and outcome. J Bone Joint Surg Br 90:770–777
Murthy A, De Angelis G, Pittet D, Schrenzel J, Uckay I, Harbarth S (2010) Cost-effectiveness of universal MRSA screening on admission to surgery. Clin Microbiol Infect 16:1747–1753
Safdar N, Narans L, Gordon B, Maki DG (2003) Comparison of culture screening methods for detection of nasal carriage of methicillin-resistant Staphylococcus aureus: prospective study comparing 32 methods. J Clin Microbiol 41:3163–3166
Giannoudis PV, Parker J, Wilcox MH (2005) Methicillin-resistant Staphylococcus aureus in trauma and orthopaedic practice. J Bone Joint Surg Br 87:749–754
Ritchie K, Bradbury I, Craig J, Eastgate J, Foster L, Kohli H et al. (2007) The clinical and cost-effectiveness of screening for MRSA. NHS Quality Improvement Scotland, HTA Report 9
Aucken HM, Ganner M, Murchan S, Cookson BD, Johnson AP (2002) A new UK stain of epidemic methicillin-resistant Staphylococcus aureus (EMRSA-17) resistant to multiple antibiotics. J Antimicrob Chemother 50:171–175
De Lucas-Villarrubia JC, Lopez-Franco M, Granzio JJ, De Lucas-Garcia JC, Gomez-Barrena E (2004) Strategy to control methicillin-resistant Staphylococcus aureus post-operative infection in orthopaedic surgery. Int Orthop 28:16–20
Murphy E, Spencer SJ, Young D, Jones B, Blyth MJG (2011) MRSA colonisation and subsequent risk of infection despite effective eradication in orthopaedic elective surgery. J Bone Joint Surg Br 93:548–551
Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D (1984) Infection and sepsis after operations for total hip or knee-joint replacement: influence of ultraclean air, prophylactic antibiotics and other factors. J Hyg (Lond) 93:505–529
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Bryson, D.J., Gulihar, A., Aujla, R.S. et al. The hip fracture best practice tariff: early surgery and the implications for MRSA screening and antibiotic prophylaxis. Eur J Orthop Surg Traumatol 25, 123–127 (2015). https://doi.org/10.1007/s00590-014-1448-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00590-014-1448-6