Dangerous Infection Becomes Public Health Issue

MRSA Infections – Where Are We, and Where Should We Be in 2008?

Courtesy of Orthopaedic Product News, Sept-Oct. 2008

Methicillin resistant staphylococcus Aureus (MRSA) infections have been a thorn in the side of orthopaedic surgeons since the 1980s, and even though the emergence of community MRSA strains has received increasing attention in our journals1, the real groundswell for a prevention plan has arisen from the catastrophic morbidity it has caused amongst infected patients and the resultant hype that is seen in the media.

The press has, in fact, alarmed the public to a point that is reminiscent of the medieval plague, as depicted in the image to the right. In this painting we see horror, confusion and panic, and no one knows what to do. It is therefore not surprising that litigation has sprung from this arena of confusion. Lawyers now advertise themselves as MRSA specialists, and they automatically label MRSA patients as victims. Orthopaedic surgeons have been caught up in this mess, and to some extent we are blamed for what is probably a simple public health issue.

Whereas orthopaedic surgeons are often individually competitive by nature, this is a time for rival hospitals and orthopaedic groups to come together and help to eliminate these infections. We need to rid ourselves of statements such as, “Don’t go to that surgeon or hospital, all of their patients get infections,” but rather realize that with any staph infection we all suffer, including the patient.

What we need to do is address this issue as a coordinated team effort, but how? When we look at the literature on PubMed, we find over 6,000 articles on MRSA alone, and so from this we need to pull out the most relevant articles.

First, what is the true prevalence of MRSA? MRSA is now the most common pathogen in soft tissue infections presenting to ED, and now accounts for the majority of staph aureus infections in hospitals. It may turn out that MRSA is so effective in taking over a patient’s natural skin flora due to horizontal transmission using plasmids. That is, skin to skin contact may allow a small amount of MRSA to rapidly overtake a patient’s entire skin flora by propagating and sharing essential DNA elements with a patient’s non pathologic methicillin sensitive staph flora.

In any case, we recognize that about eight percent of the public harbors MRSA, and these patients are almost eight times more likely to become infected with MRSA after surgery than patients who do not harbor MRSA.

Some orthopaedic centers have been proactive about this issue and now screen all of their total joint patients for MRSA prior to surgery. There are now three studies in which orthopaedic surgeons have dropped their MRSA infection rate to zero through aggressive preoperative screening and decolonization prior to allowing surgery to commence. This data makes sense if, in fact, our patients are getting infected from their own colonized MRSA. If the patient is decolonized before surgery, then the patient will have to be recolonized before an infection can ensue. Therefore, as long as patients are maintained in an active screening program, we can expect to have extremely low MRSA infection rates.

Hence, where should we be in 2008? We should not just screen major total joint and spine cases for MRSA, but should do so for all of our patients before they enter the hospital. If we think this through, a MRSA colonized patient will be unlikely to develop a postoperative infection for simple cases such as carpal tunnel surgery, but there will be an opportunity to colonize other patients—as well as the nursing staff. I have found that my patients are completely on board with this, and do not mind being screened, nor do they mind if their cases are delayed if they need to be decolonized. No one wants to be responsible for another’s infection, and even patients feel a sense of responsibility in this regard.

Therefore, we have now arrived at the time in which all patients should be screened prior to surgery, ER patients should be screened at admission and physicians and nurses should be screened yearly, just as we are screened for TB. As DNA probe technology has made MRSA screening easy (data can be made available in about an hour), there are fewer and fewer excuses to get on board with this approach.

Orthopaedic surgeons need to keep the trust of the public. We should be at the forefront of maintaining a safe surgical environment for our patients, and we should work with our colleagues to ensure that every elective patient who enters a hospital is prescreened and decolonized prior to surgery. We have the opportunity to dramatically prevent these infections, and our patients will not forgive us if we don’t take advantage of the research and technology that is currently available to make this happen.

Dr. Clifford Roberts Wheeless III has been in private practice in North Carolina for the past ten years. He is the author of Wheeless’ Textbook of Orthopaedics, an online textbook which currently draws over 500,000 visitors per month. Dr. Wheeless can be reached at crwheeless@orthonc.com.