Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Antibiotic prescribing control should not be underestimated
- Vicky V Gereis (18 July 2004)
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Those halcyon days...
- John F Bolton (19 July 2004)
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The return of stand alone orthopaedic units
- Graham C Cheung, Ashutosh Acharya (24 July 2004)
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Reducing MRSA on orthopaedic wards
- Amit Datta, Adrian Gardner(SpR) and Karl Bell(Consultant) (25 July 2004)
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Re: Reducing MRSA on orthopaedic wards
- Sydney J. Bush PhD. DOpt.. (IOSc. London), 20-22 Brook St. HULL HU2 8LA (30 July 2004)
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Misleading titles
- Keith C Judkins, Rowan House, Aberford Road, Wakefield WF1 EE (12 August 2004)
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MRSA colonised elective orthopaedic patients and where they could fit in in"ring fenced" wards.
- Mark C Norris, James Gibbs, Marc H Patterson and David Ricketts (13 August 2004)
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Re: Reducing MRSA on orthopaedic wards
- Dr. Sydney J. Bush PhD., DOpt. (IOSc. London) (29 November 2004)
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Vicky V Gereis, SHO Trauma & Orthopaedics,MSc Orthopaedics Candidate (RNOH) William Harvey Hospital, Kennington Road, Ashford, TN24 0LY
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Biant et al report eradication of Methicillin Resistant Staphylococcus Aureus (MRSA) by "ring fencing" of elective orthopaedic beds. The article outlines the association between infection rates and the low standards of hygiene, resulting from centralisation of healthcare services and the "target-meeting" mania. I agree with the authors that the cost of introducing simple measures of hygiene and housekeeping will be outweighed by lower rates of infection and shorter hospital stay(1). The Department of Health seems to have realised the importance of cleanliness and hopefully will initiate the implementation of changes towards cleaner hospitals(2). However the authors did not mention changes in antibiotic prescribing during the observation and the ring fencing period. The correlation of MRSA colonization with the amount and nature of antibiotics prescribed has been emphasized in many studies(3). The importance of controlled antibiotic prescribing according to local policies cannot be overemphasised and regular auditing and training of junior doctors is strongly recommended. 1.Biant L, Teare L, Williams W, Tuite J. Eradication of methicillin resistant Staphylococcus Aureus by "ring fencing" of elective orthopaedic beds. BMJ 2004;329:149-151 (17 July). 2. Department of Health, publications policy and guidance.Towards cleaner hospitals and lower rates of infection :A summary of action. www.dh.gov.uk 12/07/04 3. Belkum a, Verbrugh H. 40 years of methicillin resistant Staphylococcus aureus. BMJ 2001;323:644-645 (22 September) Competing interests: None declared |
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John F Bolton, Clinical Fellow in Urology Bristol Royal Infirmary, BS2 8HW
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This paper by Biant, et al, is important (1). It provides statistical evidence that modern hospital policy is detrimental to patients, and impedes the provision of healthcare. Think back to those days of yesteryear, when only orthopaedic (or, in our case, urology) patients were on the regularly cleaned orthopaedic (urology) ward. They were looked after by nursing staff trained in that field and regularly employed on that ward. The patients were not only better off for the convenience of this arrangement, but got less infections, suffered less mortality, and were more likely to leave with as many limbs as they arrived with. Oh, and we got more work done, too. Isn't it time we gave serious thought to returning to those halcyon days? If the government gives us our beds back by moving the outliers and employs nurses for more than a shift at a time, infection rates and waiting lists will fall, and the newpaper headlines will focus on something else for a change. Ref: 1. Leela C Biant, E Louise Teare, William W Williams, and Jeremy D Tuite. Eradication of methicillin resistant Staphylococcus aureus by "ring fencing" of elective orthopaedic beds. BMJ 2004; 329: 149-151 Competing interests: None declared |
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Graham C Cheung, SHO Orthopaedics Royal Liverpool Childrens Hospital, Ashutosh Acharya
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Editor - Biant et al report on their "ring fencing" of elective orthopaedic beds in order to eradicate methicillin resistant Staphylococcus aureus. (1) We would like to congratulate the authors on an excellent article, which would encourage many orthopaedic units to change their practice and act similarly. One question does arise though. There is no mention of the number of cases that were done each year, to give the rate of infection. If the stand alone unit was doing a similar number of cases, then there was a true rise in the infection rate after April 1998. Prior to 1998 approximately 27 infections occurred in the preceding 10 years (mean = 2.7). Even when all the new precautions were taken from July 2000, there were 15 infections in 12 months in the "ring fenced" district general hospital; more than 5 times the number of infections than in the stand alone unit. Does this imply that stand alone orthopaedic units are the way forward in reducing post-operative infection? (1) Biant LC, Teare EL, Williams WW, Tuite, JD. Eradication of methicillin resistant Staphylococcus aureus by "ring fencing" of electiove orthopaedic beds. BMJ 2004;329:149-151. (17 July) Competing interests: None declared |
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Amit Datta, SpR Trauma & Orthopaedics Alexandra Hospital Redditch B98 7UB, Adrian Gardner(SpR) and Karl Bell(Consultant)
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Editor-Biant et al report excellent results after "ring fencing" of elective orthopaedic beds.(1) More importantly they have changed the culture of infection control by involving staff, patients and visitor in a collective responsibility to reduce hospital aquired infection. Their methods have highlighted that elective arthroplasty is an area that requires special attention with regard to infection control in order to achieve excellent long term results. At the Alexandra Hospital Redditch we have also instigated a methicillin resistant staphylococcus aureus(MRSA) screening programme resulting in a "ring fenced" orthopaedic beds. Our admission criteria, though not as restrictive as that used in Chelmsford, required a set of clear MRSA swabs six weeks prior to admission. Any positive cases were treated with a decontamination regimen and subsequently admitted when swabs were clear. Due to a modular ward system, at times when orthopaedic throughput was reduced, whole bays of beds could be used by other specialities as they could be accessed from adjacent wards. This prevented ineffcient bed utilisation for the hospital's acute service. In the year prior to our screening policy there were 16 cases of MRSA on the ward occuring in both orthopaedic and non orthopaedic cases after screening this had reduced to only 2. From October 2001 to December 2002 our infection rate for total knee replacements was 0.21%(1/468)compared to 2.1%(179/8630) nationwide p=0.002. For total hip replacement our infection rate was 1.31%(5/380)compared to 3.8%(603/15691) nationwide p=0.01. Nationwide data was obtained from the Nosocomal Infection National Surveillance Service(NINNS). We feel separating acute admissions from elective orthopaedic admissions has lead to a significant reduction in infection rates on our orthopaedic ward. Due to more control over the admission policy we demonstrated a 30% increase in arthroplasty cases from 2001(482) to 2002(629) utilising the same number of beds. We strongly advocate the excellent set up in Chelmsford that has lead to a significant cultural change in the bahaviour of staff, patients and visitors on elective orthopaedic wards. The changes may though be difficult to achieve in all trusts in the short term as they will prove labour intensive. Our model although far from perfect illustrates what can be achieved with just screening that results in isolating vulnerable arthoplasty cases from acute admissions that carry a higher risk of MRSA carriage.(2) 1 Biant L,Teare E,Williams W,Tuite J Eradication of methicillin resistant Stahylococcus aureus by "ring fencing" of elective orthopaedic beds BMJ 2004; 329: 149-151 2 Surveillance of Hospital Acquired Bacteraemia in English Hospitals 1997-2002 Nosocomal Infection National Surveillance Service Competing interests: None declared |
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Sydney J. Bush PhD. DOpt.. (IOSc. London), UK optometrist/contact lens practitoner , Consultant in CardioRetinometry AntiCoronary Clinics(UK) Ltd., 20-22 Brook St. HULL HU2 8LA
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From Dr. Sydney J Bush PhD. DOpt. (IOSc. London) It is increasingly widely known that concentrated ascorbate, especially at plasma levels that can be safely achieved by intravenous application, has successfully overcome conditions formerly regarded as incurable. Nakanishi (1992 and 1993) reported that application of ascorbate topically to bedsores was able to remarkably enhance the bacteria killing effect of antibiotics. Nakanishi also noted that Staph. aureus which had been antibiotic resistant prior to this treament, 'disappeared from the area.' (Thomas E.Levy.MD. JD. "Vitamin C, Infections and Toxins. Curing the incurable" 2002 XLibris Corp. ISBN 1-4010 6964-9) References: Nakanishi T. (1992) "A report on a clnical experience of which has successfully made several antibiotic resistant bacteria (MRSA etc) negative on a bedsore" Article in Japanese Igaku Kenkyu. Acta Medica 62(1):31-37 Nakanishi T. (1993) "A report on the therapeutical experiences which have made several antibiotics resistant bacteria (MRSA etc.) negative on bedsores and respiratory organs." Article in Japanese. Igaku Kenkyu. Acta Medica 63(3):95-100. Klenner Fred. MD. FCCP. Too many to list in J. of Southern Medicine and Surgery and Tristate Medical Journal.1949 onwards. Cathcart R. (1981) VITAMIN C, TITRATING TO BOWEL TOLERANCE, ANASCORBEMIA, AND ACUTE INDUCED SCURVY Medical Hypotheses, 7:1359-1376, 1981 Sydney J Bush Competing interests: None |
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Keith C Judkins, Medical Director & Consultant Anaesthetist Mid Yorkshire Hospitals NHS Trust, Rowan House, Aberford Road, Wakefield WF1 EE
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This paper is interesting and informative. But what measure caused the reduction in observed infection particularly MRSA? Was it "ring- fencing" as the paper's title suggests? It is certainly this conclusion that other responders have almost gleefully latched onto, backed by their preconceptions. Yet the paper describes no less than six measures used in the study in addition to ring-fencing. Which one did the trick? Is it likely that one of them alone was the key measure, or that they worked in synergy? I'm not decrying the value of ring-fencing beds. I believe this has a place in effective infection control. Further, it seems to me commonsense that the 'target culture' has had a detrimental effect on infection rates, but I would venture to suggest that this may be because we have taken our eye off the infection control ball, not directly because of targets. This interesting and valuable paper does not 'prove' that ring- fencing works, or that the target culture is to blame for rising hospital- acquired infection; it shows that rigorous infection control (including ring-fencing) works. And that should be good news! It does not contradict the view that, with rigorous attention to BOTH goals, it should be perfectly possible to achieve good infection control AND achieve targets. This is not the first time that the BMJ has published a paper with a misleading title and I doubt it will be the last. Let's not be misled by poor titles into misunderstanding the detail of a good paper. Competing interests: None declared |
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Mark C Norris, Clinical Fellow Orthopaedics Princess Royal Hospital, Lewes Road, Haywards Heath West Sussex. RH16 4EX, James Gibbs, Marc H Patterson and David Ricketts
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To the editor We read with interest the article by Biant et al who stated that “ring fencing” of elective orthopaedic beds significantly reduced post- operative infections [1]. Harvey and Benfield have shown that it is safe to continue with joint replacement surgery when other patients on the same ward have active MRSA as long as strict infection control measures are followed [2]. In our department in 2000 we had concerns regarding an increase in joint infections. At that time we had a general orthopaedic ward with elective and trauma orthopaedic patients as well as medical “outliers”. Infection control measures were reviewed and re-emphasized to ward and theatre staff. MRSA patients were isolated. In 2001 although our infection rates improved MRSA joint infection was still a problem with 6 further cases all requiring revision surgery. At this point a separate elective orthopaedic ward was set up with screening of all admissions for MRSA at the pre-admission clinic 2 weeks prior to their operation date. Trauma patients were admitted to a separate bay on our trauma ward and screened, once clear moved into the main trauma ward. Elective patients shown to have colonization with MRSA were given oral and topical eradication therapy (rifampicin and sodium fusadate orally and triclosan and bactroban topically). This was given 1 week prior to surgery, aiming to finish the course on their admission date. They were admitted to a side room and barrier nursed on the elective ward. Since the implementation of the above we have not had a surgical site infection with MRSA. Of the 19 patients shown to have MRSA pre-operatively, who underwent eradication therapy, there have been no surgical site infections to date (August 2004). The hard work of infection control and all staff involved in orthopaedic inpatients has reduced MRSA infections. These efforts were recognised in the latest National Audit Office progress report on hospital-acquired infection [3]. Management of elective cases with MRSA colonisation is becoming more of a problem. We have had a marked increase of colonised patients found at pre-admission clinic in the last 6 months. This has increased from 0.9% (13 out of 1391) in 2003 to 2.8% (28 out of 977) in the last 6 months. We feel that delays in operation of MRSA colonized patients while waiting for negative swabs can be avoided. This has benefits in not having to change operative lists at short notice and there is less chance of re- colonization prior to admission following negative results after eradication therapy. We therefore agree with Biant et al that a dedicated elective orthopaedic ward significantly reduces post-operative infections with MRSA. We also feel that MRSA colonized patients found at pre-admission clinic can undergo their operation without significant delay following eradication therapy and barrier nursing on the dedicated elective ward. References 1. Biant LC, Teare EL, Williams WW, Tuite JD. Eradication of methicillin resistant Staphylococcus aureus by “ring fencing” of elective orthopaedic beds. BMJ 2004;329:149-51. 2. Harvey JR, Benfield JEC. Preventing methicillin-resistant Staphylococcus aureus infection in joint replacements: a new problem requiring old solutions. Ann R Coll Surg Engl 2004;86: 122-124. 3. Report by the Comptroller and Auditor General - HC 876 Session 2003-2004: Improving patient care by reducing hospital acquired infection: a progress report. http//www.nao.org.uk/publications/nao-reports/03-04/0304876.pdf Competing interests: None declared |
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Dr. Sydney J. Bush PhD., DOpt. (IOSc. London), Consultant in CardioRetinometry AntiCoronary Clinics (UK) Ltd. 20-22 Brook St. HU2 8LA
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Letter to e-BMJ 29th Nov. 2004 Re Reducing MRSA on orthopaedic wards I am unable to understand why, after publication of the evidence I submitted on 30th July quoting the two papers on the efficacy of ascorbate in killing MRSA in Japanese research by Nakanishi T. and available on Entrez PubMed, no interest at all has been shown. Could it not be the case that non-toxic IV ascorbate would provide an instant solution to these infections and many others, and may one ask why it has not been done? There is not even a negative paper to be found in the literature on the subject of multigram doses of ascorbate IV - only many successes and positively beneficial sequelae. The prompt resolution of many bacterial and viral infections by ascorbate IV have been reported by Klenner F and others from 1949 onwards. If the public has to wait much longer as the death rate mounts, might not MRSA patients start discharging themselves from hospitals in order to start injecting themselves? I would. Sydney J Bush PhD. DOpt. (IOSc. London) Competing interests: None |
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