Treatment protocols for infections, MRSA vary throughout Europe

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        Treatment protocols for infections, MRSA vary throughout Europe

        March 2010

        The potential for surgical site infections and methicillin-resistant Staphylococcus aureus remain at the forefront of surgeons’ minds. While some European orthopaedists note a steady rate of surgical site infections and methicillin-resistant Staphylococcus aureus in their respective countries, others cite these conditions as growing problems and highlight an upward trend in the rates of methicillin-resistant Staphylococcus epidermis cases being seen.

        The protocols for the prevention and treatment of methicillin-resistant Staphylococcus aureus (MRSA) and surgical site infections (SSIs) throughout Europe are as varied as the rates. As the war against infection-causing bacteria continues, some leaders in the field point to biofilms, “smart” implants and specific infection centers as future weapons to be included in the orthopaedists’ arsenal.

        In the United Kingdom, every national trust hospital is mandated to report their rates of MRSA bacteraemia and have those rates meet a certain target.

        In a National Health Service (NHS) Department of Health (DH) report published in 2005, the Health Protection Agency Communicable Disease Surveillance Centre found the total number of MRSA-related infections in England’s acute trusts from April to September of that year to be 3,580. This number ran almost parallel to the 3,616 recorded over the same period in 2001; 3,584 in 2002; 3,749 in 2003 and 3,525 in 2004.

        The DH pointed out in the report that such findings must be “interpreted with care,” and noted the following:

          [*]The individual trust figures do not reflect all MRSA infection or carriage so much as the burden of serious infections associated with MRSA bacteria (or blood stream infections);
          [*]Reports of MRSA infection in a particular trust did not necessarily originate within that trust;
          [*]Trusts vary in specialty and scope — with some of these specialties making them more vulnerable to infection — and so comparing them with one another can be disingenuous;
          [*]During a 6-month period, one or two reports in a small trust can cause large fluctuation in that trust’s reported rate.

        No step-by-step protocol

        “SSI, particularly with respect to MRSA, is hopefully a decreasing problem in the U.K. ”
        — Robert Townsend, MBCHB, MSc, DTMH, FRCPath

        According to Robert Townsend, MBCHB, MSc, DTMH, FRCPath, a consultant microbiologist with Sheffield Teaching Hospitals in Sheffield, U.K., there often may be no step-by-step protocol specifically designed to combat or manage MRSA infections, so all trusts should adopt a search-and-destroy approach to MRSA cases.

        “Strictly speaking, we do not have any fixed antibiotic protocols for the management of MRSA infections,” Townsend told Orthopaedics Today Europe. “Our guideline, for example, simply says to contact the microbiologist.

        “We do, however, operate a search-and-destroy screening protocol to all admissions to the trust,” he added.

        Townsend said, a screen protocol means that surgery can be delayed to allow de-colonization or performed under appropriate antibiotic prophylaxes.

        “This would not, however, prevent infection acquired on the ward postoperatively,” he said. “This is where good hand hygiene and high compliance rates with hand hygiene audits come in.”

        Townsend credited the screening protocol with being at least part of the reason that SSIs and MRSA are hopefully diminishing issues now in the U.K. than they were in the past, which is certainly true of Sheffield Teaching Hospitals NHS Foundation Trust.

        “SSI, particularly with respect to MRSA, is hopefully a decreasing problem in the U.K.,” Townsend said. “If you use the bacteraemia rates as a surrogate for severe MRSA infection, then there has been a very real decrease across the U.K.”

        Prevalence in the U.K.

        Regarding the prevalence of SSI and MRSA in the U.K. when compared to other countries in Europe, Townsend was unsure if there was any one facet on which the blame could be placed.

        “I am not really sure — there could be many factors,” he said.

        Townsend said that the differences between surgical site surveillance and reporting — such as case ascertainment and publication — across the European Union (EU) may be one factor.

        “I am not sure whether all EU countries collect and publish the same data in the same way as we do,” he said.

        As for bed occupancy rates across the NHS, Townsend said that these numbers tend to be high “year round,” a fact which can potentially impact infection control practices.

        Additionally, he said, the choices of antibiotic prophylaxis could be different in various countries throughout EU.

        Christophe Pattyn, MD, PhD, noted that surgeons and nurses in Belgium have become more aware of methicillin-resistant bacteria and are taking preventative measures on the ward.


        The incidence of SSIs depends on the severity of the procedure, according to Christophe Pattyn, MD, PhD, an orthopaedist with the Department of Orthopaedic Surgery and Traumatology, at Ghent University Hospital in Belgium. In Belgium, the rate of infections from primary hip or knee procedures is about 1%, between 5% and 10% for revisions. MRSA occurs in about 8% of infected cases, he said.

        Belgian surgeons have also noted a shift in prevalence from S. aureus to Staphylococcus epidermis.

        MRSA is decreasing, but methicillin-resistant Staphylococcus epidermis (MRSE) increasing, Pattyn told Orthopaedics Today Europe. However, he noted that the incidence of methicillin resistance for both germs is an estimated 10%.

        “We have the impression, even in our hospital, that MRSA is going down,” Pattyn said. “Also with MRSE, in 2 to 3 years, we have the impression that it is going [to go] down because of the infection prevention.”

        He noted that surgeons and nurses in the country have become more aware and are taking preventative measures on the ward such as disinfecting their hands when going from one patient to another. Also, they have found that decreased length of stay is also advantageous in preventing methicillin-resistant infections.

        Pattyn said that the protocol in his country for treating SSIs is time-dependent.

        “If infection occurs within 6 weeks after surgery, then we are very aggressive in order to maintain the implant,” he said. “We go back to theater, open the wound, clean it, debride it and, if necessary, we do it again after a week [for] up to three times. If that does not work, then we have to remove the prosthesis.”

        In cases when the infection occurs later than 6 weeks after arthroplasty surgery, surgeons perform a two-stage revision procedure that includes removal of the implant, a period of antibiotic treatment and re-implantation.

        The antibiotic treatment typically combines vancomycin and rifampicine. “I think that vancomycin is the most important one,” Pattyn said. “It has good bone penetration when given in adequate doses. Rifampicine, on the other hand, works on the biofilm of the prosthesis, . It also has less chance for resistance compared to rifampicine. But, an objection might be renal failure, so you have to adapt the dose for that problem.”


        About 15% of patients with an infection in Germany will have MRSA, according to Rudolph Ascherl, MD, the medical director of the Orthopaedic Hospital Rummelsberg. In his experience, diabetic foot patients are at high-risk for the bacteria, and 35% to 40% of these patients develop an MRSA infection.

        Some surgeons are also noticing the emergence of MRSE.

        “In my point of view, it is harder to treat than MRSA,” Ascherl told Orthopaedics Today Europe. “You cannot decontaminate patients from their skin, and the recurrency rate, in our experience, is as much as in MRSA or a little bit higher.”

        He noted that the protocol for preventing and treating MRSA includes proper patient screening, administering prophylaxis and isolating the patient.

        Surgeons commonly use intraoperative doses of vancomycin and rifampin to prevent SSIs. In the event of an infection after arthroplasty, surgeons at his hospital perform two-stage revision procedures.

        “One should always use a multiple-stage revision, because the recurrency rate is so high,” Ascherl said. “The recurrency rate for us now is about 20%.”

        Challenges, new developments

        To better tackle SSIs, German researchers are developing biofilms that reduce bacteria, coated implants and bone cements.

        “We are now doing a study with silver bone cement to prevent contamination of the cement,” Ascherl said. In addition, he is establishing two specialized centers in the country for the treatment of patients with methicillin-resistant germs and those with recurrent infections.

        He noted that the current efforts to get a handle on MRSA and SSIs are not enough. “It costs a lot of money to do all of these screening measures and isolations,” Ascherl said. “Sometimes these patients are not admitted to hospitals because no one wants to admit them. This is a big burden for the hospitals that treat these patients. Sometimes we have up to 14 patients with MRSA.”


        In Norway, the recorded SSI and MRSA rates are low, according to Eivind Witsø, MD, PhD, a consultant orthopaedic surgeon in the Septic Unit at St. Olav’s University Hospital in Trondheim, Norway.

        “According to the Norwegian Surveillance System for Hospital-Acquired Infections (NOIS), the incidence of superficial and deep postoperative infections after primary total hip arthroplasties are 2.1% and 2.0%, respectively,” Witsø told Orthopaedics Today Europe. “According to the Norwegian MRSA reference laboratorium, there were two MRSA infections registered in the musculoskeletal system in Norway during 2008.”

        Patients with MRSA there are isolated from the general population, but are otherwise treated in a similar manner as patients with other staphylococci infections.

        Witsø noted that papers published by the Norwegian Arthroplasty Register, which is owned by the Norwegian Orthopaedic Association, offer surgeons guidance regarding the prevention of postoperative infections.

        “In Norway, the use of antibiotic-containing bone cement and the use of pre- and postoperative prophylactic antibiotics, [such as] doses and administration, are to a high degree inspired by the papers published by the Norwegian Arthroplasty Register,” Witsø said.

        Despite the advances made regarding the prevention of postoperative infections, he said that much needs to be done in this area including the establishment of better methods to identify high-risk patients. He also noted that alternative techniques such as ultra-clean air, “smart implants” and prostheses that inhibit biofilms may play a greater role in the future.

        “Since antibiotics as we know them will have less importance due to the increasing rate of antibiotic resistance, we have to make other techniques for avoiding infection a priority,” Witsø said.

        – by Gina Brockenbrough and Robert Press

        Full article, with discussion:

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