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Soft tissue and bone MRSA infections
Injury, Int. J. Care Injured 42 (2011) S5, S1–S2
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Soft tissue and bone MRSA infections P.V. Giannoudisa , R. Townsendb , S. Homer-Vanniasinkamc , M.H. Wilcoxd a Academic
Department of Trauma & Orthopaedic surgery, School of Medicine University of Leeds, b Department of Microbiology, Northern General Hospital Sheffield, c Academic Department of Vascular Surgery, School of Medicine University of Leeds, d Department of Microbiology, Leeds Teaching Hospitals & University of Leeds, UK
A great percentage of orthopaedic patients are elderly people who attend the A/E department usually having sustained a proximal femur fracture after a minor mechanical fall.1–4 Many of these patients reside in residential or nursing homes. These patients are generally in poorer health in comparison with those living independently, and are prone to post-operative wound infections.5,6 Post-operative wound infections due to methicillin-resistant Staphylococcus aureus (MRSA) continue to be a major concern to clinicians and the public, and to the commissioners and providers of health care. In particular, orthopaedic trauma surgery is a surgical specialty which uses a great variety of implants to treat skeletal injury.7–10 Once bacteria, either seeded during the open surgery or carried by the bloodstream, adhere on the implant surface they become very difficult to eradicate.11,12 MRSA is implicated in up to 30–50% of all post-operative surgical infections in trauma and orthopaedic surgery.13 MRSA has been an increasing problem since its isolation in England in 1961.14 It is easily transmissible from one person to another. MRSA infection can be endogenous (from the patient’s own resident MRSA) or exogenously acquired, by cross-infection from either an asymptomatic carrier or a patient with MRSA infection. MRSA infections result in an increased hospital stay, increased risk for other hospitalised patients and in great financial cost of treatment, due to implementation of further treatment methods, longer need for IV antibiotics, closer patient monitoring and additional surgical intervention. Bloodstream invasion by MRSA can lead to septicaemia, which is associated with 10–20% mortality. The publicity surrounding MRSA has never been greater. The introduction by the Department of Health in the United Kingdom of mandatory surveillance schemes for both MRSA bacteraemia and surgical site infection (SSI) in orthopaedic surgery from 2001 and 2004, respectively, highlights the importance of nosocomial infection. Surveillance of bacteraemia caused by MRSA in the UK has involved collection of data from hospital microbiology laboratories via several mechanisms. These include a voluntary reporting scheme that has been operational in England and Wales since 1989 and mandatory reporting schemes that have been running independently in England, Wales, Scotland and Northern Ireland since 2001. Another surveillance scheme is also available that was created by participating sentinel laboratories that submit isolates for centralised susceptibility testing (Bacteraemia Resistance Surveillance Programme run by the BSAC). * Corresponding author. Professor P.V. Giannoudis, BSc, MB, MD, FRCS, Department of Trauma and Orthopaedics, Academic Unit, Clarendon Wing, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, LS1 3EX, United Kingdom. Tel.: +44 113 392 2750. E-mail address: [email protected] (P.V. Giannoudis). 0020-1383/ $ – see front matter © 2011 Elsevier Ltd. All rights reserved.
Many approaches have been used in order to identify patients who are infected or colonised with MRSA. To date, however, there have been few studies which detail the cost effectiveness of these methods. Department of Health policy in England now requires that all elective and acute admissions are screened for MRSA; in addition, some high-risk units (e.g. orthopaedic wards) undertake discharge and additional patient screening and staff screening if a single case is detected, and isolation of carriers.13 Glycopeptides are the mainstay of MRSA treatment in the United Kingdom with vancomycin and teicoplanin being the drugs of choice. Both are given parentally, although vancomycin is less well tolerated and the penetration of teicoplanin into bone is better than that of vancomycin. Although teicoplanin can be administered as a bolus dose and can therefore be given on an out-patient basis, both antibiotics are generally regarded as suitable for in-patient treatment. The development of the oxazolidinone linezolid was an important development in the pharmacotherapy of MRSA infection. Linezolid inhibits an early step in protein synthesis and has excellent tissue penetration and 100% bioavailability after oral administration. Linezolid compares favourably with vancomycin, specifically against MRSA causing skin and soft tissue infection.15 Linezolid is recommended as an alternative when conventional therapy has failed or is not tolerated.16 It allows oral, and hence out-patient, administration. However, the apparent increase in side effects, particularly the bone-marrow suppression seen on prolonged administration, means that it should be used under careful observation.17 Pooling the findings from different surveillance programmes, one can obtain a more detailed and reliable picture of the problem posed by MRSA. There was a dramatic rise in the total numbers of cases of S. aureus bacteraemia during the 1990s and also an increase in the proportion of such cases that are associated with MRSA.18 However, most recent data have indicated a reversal of these tendencies.19 Characterisation of isolates of MRSA shows a marked temporal relationship between the rise in MRSA bacteraemias and the emergence and spread of two strains of epidemic MRSA, EMRSA-15 and EMRSA-16. Surveillance and control of MRSA infection continue to be high profile and further developments to the mandatory surveillance system in England are likely in the near future.20 What are the recent epidemiological data however on MRSA infections? In Scandinavia the level of methicillin resistance in S. aureus isolates was found to be <1%, whereas in other countries such as Spain, France and Italy greater than 30% levels were noted.21 Other authors have reported rates between 2% to 58% in different countries within Europe.22,23 The prevalence is estimated to be at least 10% in most European countries.18 De Lucas-Villarrubia et al. showed the prevalence of MRSA to be 1.6% within an
S2
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 42 (2011) S5, S1–S2
orthopaedic department compared with 0.3% within the general hospital setting.24 Tai et al. reported similar results, with 1.6% of the total orthopaedic admissions to a London teaching hospital being either infected with or colonised by MRSA.25 The SENTRY study showed that although the overall numbers of staphylococcal infections within an orthopaedic setting were low in comparison with those in general medicine or intensive care, the level of methicillin resistance was high.22 In a study that was designed to assess the epidemiology of SSI in orthopaedic trauma surgery following acetabular fracture open reduction and internal fixation, the prevalence of MRSA was reported to be 0.9%.26 O’Malley et al.27 examined the prevalence of community-acquired MRSA (CA-MRSA) hand infection in an urban setting. Out of 85 patients studied, the overall prevalence rate of CA-MRSA in hand infections was 55%.27 In a retrospective, multicentre cohort study, out of 504 patients treated for neck of femur fracture, 22 (5.6%) developed SSI, of which 7 were caused by MRSA (1.4%) (32% out of all the bacteria isolated). The authors concluded that SSI after surgery for femoral neck fracture is severe, and MRSA is the most frequently encountered aetiologic pathogen.28 Nixon et al.29 examined the incidence of infection with MRSA in patients admitted in a busy trauma unit over a 3-year period. The influence of MRSA status at the time of their admission was examined, together with age, gender and diagnosis, using multivariant analysis. Of 2473 patients, 79 (3.2%) were MRSA carriers at the time of admission and 2394 (96.8%) were MRSA-negative. Those carrying MRSA at the time of admission were more likely to develop surgical site infection with MRSA (7 of 79 patients, 8.8%) than nonMRSA carriers (54 of 2394 patients, 2.2%, p < 0.001). Further analysis showed that hip fracture and increasing age were also risk factors with a linear increase in relative risk of 1.8% per year. MRSA carriage at admission, age and the pathology were all associated with an increased rate of developing MRSA wound infection.29 In another 5-year prospective study, the impact of MRSA was assessed on an orthopaedic unit. We identified 318 cases of MRSA, representing 0.76% of all admissions (41 971). A total of 240 (76%) cases was colonised with MRSA, and 120 (37.7%) were infected. A total of 115 cases (36.6%) was colonised or infected on admission. The authors concluded that the financial burden of MRSA is increasing, highlighting the need for progress in understanding how to control this resistant pathogen more effectively.30 Overall, from the different studies available in the literature it appears that the incidence of MRSA infection is 1–5% in trauma patients. In this special issue a number of articles have been compiled together to highlight the current issues surrounding MRSA infection in the trauma and orthopaedic and vascular disciplines. We are aware that not all of the important issues can be covered but we hope that this supplement will enhance the clinician’s knowledge on this ever important clinical subject. Competing interests The authors have no conflicts of interest to declare. References 1. Kalra S, Williams A, Whitaker R, Hossain M, Curtis G, Giles M, et al. Subclinical thyroid dysfunction does not affect one-year mortality in elderly patients after hip fracture: a prospective longitudinal study. Injury 2010 Apr;41(4):385–7. 2. Bennet SJ, Berry OM, Goddard J, Keating JF. Acute renal dysfunction following hip fracture. Injury 2010 Apr;41(4):335–8. 3. Matharu GS, Porter KM. Timing of surgery for hip fractures. Injury 2010 Jul; 41(7):1060–1.
4. Najran PS, Matharu GS, Porter KM. Non-operative treatment following hip fracture. Injury 2010 Jul;41(7):1062–3. 5. Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS. Surgical site infection in the elderly following orthopaedic surgery risk factors and outcomes. J Bone Joint Surg Am 2006;88:1705–12. 6. Pollard TCB, Newman JE, Barlow NJ, Price JD, Willett KM. Deep wound infection after proximal femoral fracture: consequences and costs. J Hosp Infect 2006;63: 133–9. 7. Parker MJ, Stedtfeld HW. Internal fixation of intracapsular hip fractures with a dynamic locking plate: initial experience and results for 83 patients treated with a new implant. Injury 2010 Apr;41(4):348–51. 8. Roy L, Laflamme GY, Carrier M, Kim PR, Leduc S. A randomised clinical trial comparing minimally invasive surgery to conventional approach for endoprosthesis in elderly patients with hip fractures. Injury 2010 Apr;41(4): 365–9. 9. Parker MJ, Ali SM. Short versus long thread cannulated cancellous screws for intracapsular hip fractures: a randomised trial of 432 patients. Injury 2010 Apr; 41(4):382–4. 10. Parker MJ, Pryor G, Gurusamy K. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures: a long-term follow-up of a randomised trial. Injury 2010 Apr;41(4):370–3. 11. Malizos KN, Gougoulias NE, Dailiana ZH, Varitimidis S, Bargiotas KA, Paridis D. Ankle and foot osteomyelitis: treatment protocol and clinical results. Injury 2010 Mar;41(3):285–93. 12. Megas P, Saridis A, Kouzelis A, Kallivokas A, Mylonas S, Tyllianakis M. The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method. Injury 2010 Mar;41(3):294–9. 13. Giannoudis PV, Parker J, Wilcox MH. Methicillin-resistant Staphylococcus aureus in trauma and orthopaedic practice. J Bone Joint Surg Br 2005;87-B:749–54. 14. Jevons MP. Celbenin-resistant staphylococci. Br Med J 1961;1:124–5. 15. Wilcox MH. Efficacy of linezolid versus comparator therapies in Gram-positive infections. J Antimicrob Chemother 2003;51(Suppl 2):27–35. 16. Cepeda JA, Whitehouse T, Cooper B, Hails J, Jones K, Kwaku F, et al. Linezolid versus teicoplanin in the treatment of Gram-positive infections in the critically ill: a randomized, double-blind, multicentre study. J Antimicrob Chemother 2004; 53:345–55. 17. Harwood PJ, Giannoudis PV. The safety and efficacy of linezolid in orthopaedic practice for the treatment of infection due to antibiotic-resistant organisms. Expert Opin Drug Saf 2004;3:405–14. 18. European Antimicrobial Resistance Surveillance System (EARSS). http://www.earss.rivm.nl (accessed 14/12/10). 19. Health Protection Agency. Mandatory bacteraemia surveillance scheme 2004. 20. Johnson AP, Pearson A, Duckworth G. Surveillance and epidemiology of MRSA bacteraemia in the UK. J Antimicrob Chemother 2005 Sep;56(3):455–62. 21. Voss A, Milatovic D, Wallrauch-Schwarz C, Rosdahl VT, Braveny I. Methicillinresistant Staphylococcus aureus in Europe. Eur J Clin Microbiol Infect Dis 1994;13: 50–5. 22. Fluit AC, Wielders CL, Verhoef J, Schmitz FJ. Epidemiology and susceptibility of 3,051 Staphylococcus aureus isolates from 25 university hospitals participating in the European SENTRY study. J Clin Microbiol 2001;39:3727–32. 23. Jones ME, Karlowsky JA, Draghi DC, Thornsberry C, Sahm DF, Nathwani D. Epidemiology and antibiotic susceptibility of bacteria causing skin and soft tissue infections in the USA and Europe: a guide to appropriate antimicrobial therapy. Int J Antimicrob Agents 2003;22:406–19. 24. De Lucas-Villarrubia JC, Lopez-Franco M, Granizo JJ, De Lucas-Garcia JC, GomezBarrena E. Strategy to control methicillin-resistant Staphylococcus aureus postoperative infection in orthopaedic surgery. Int Orthop 2004;28:16–20. 25. Tai CC, Nirvani AA, Holmes A, Hughes SP. Methicillin-resistant Staphylococcus aureus in orthopaedic surgery. Int Orthop 2004;28:32–5. 26. Suzuki T, Morgan SJ, Smith WR, Stahel PF, Gillani SA, Hak DJ. Postoperative surgical site infection following acetabular fracture fixation. Injury 2010 Apr; 41(4):396–9. 27. O’Malley M, Fowler J, Ilyas AM. Community-acquired methicillin-resistant Staphylococcus aureus infections of the hand: prevalence and timeliness of treatment. J Hand Surg Am 2009 Mar;34(3):504–8. 28. Merrer J, Girou E, Lortat-Jacob A, Montravers P, Lucet JC; Groupe de Recherche sur l’Antibioprophylaxie en Chirurgie. Surgical site infection after surgery to repair femoral neck fracture: a French multicenter retrospective study. Infect Control Hosp Epidemiol 2007 Oct;28(10):1169–74. 29. Nixon M, Jackson B, Varghese P, Jenkins D, Taylor G. Methicillin-resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J Bone Joint Surg Br 2006 Jun;88(6):812–7. 30. Roche SJ, Fitzgerald D, O’Rourke A, McCabe JP. Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre: a five-year analysis. J Bone Joint Surg Br 2006 Jun;88(6):807–11.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Soft tissue and bone MRSA infections P.V. Giannoudisa , R. Townsendb , S. Homer-Vanniasinkamc , M.H. Wilcoxd a Academic
Department of Trauma & Orthopaedic surgery, School of Medicine University of Leeds, b Department of Microbiology, Northern General Hospital Sheffield, c Academic Department of Vascular Surgery, School of Medicine University of Leeds, d Department of Microbiology, Leeds Teaching Hospitals & University of Leeds, UK
A great percentage of orthopaedic patients are elderly people who attend the A/E department usually having sustained a proximal femur fracture after a minor mechanical fall.1–4 Many of these patients reside in residential or nursing homes. These patients are generally in poorer health in comparison with those living independently, and are prone to post-operative wound infections.5,6 Post-operative wound infections due to methicillin-resistant Staphylococcus aureus (MRSA) continue to be a major concern to clinicians and the public, and to the commissioners and providers of health care. In particular, orthopaedic trauma surgery is a surgical specialty which uses a great variety of implants to treat skeletal injury.7–10 Once bacteria, either seeded during the open surgery or carried by the bloodstream, adhere on the implant surface they become very difficult to eradicate.11,12 MRSA is implicated in up to 30–50% of all post-operative surgical infections in trauma and orthopaedic surgery.13 MRSA has been an increasing problem since its isolation in England in 1961.14 It is easily transmissible from one person to another. MRSA infection can be endogenous (from the patient’s own resident MRSA) or exogenously acquired, by cross-infection from either an asymptomatic carrier or a patient with MRSA infection. MRSA infections result in an increased hospital stay, increased risk for other hospitalised patients and in great financial cost of treatment, due to implementation of further treatment methods, longer need for IV antibiotics, closer patient monitoring and additional surgical intervention. Bloodstream invasion by MRSA can lead to septicaemia, which is associated with 10–20% mortality. The publicity surrounding MRSA has never been greater. The introduction by the Department of Health in the United Kingdom of mandatory surveillance schemes for both MRSA bacteraemia and surgical site infection (SSI) in orthopaedic surgery from 2001 and 2004, respectively, highlights the importance of nosocomial infection. Surveillance of bacteraemia caused by MRSA in the UK has involved collection of data from hospital microbiology laboratories via several mechanisms. These include a voluntary reporting scheme that has been operational in England and Wales since 1989 and mandatory reporting schemes that have been running independently in England, Wales, Scotland and Northern Ireland since 2001. Another surveillance scheme is also available that was created by participating sentinel laboratories that submit isolates for centralised susceptibility testing (Bacteraemia Resistance Surveillance Programme run by the BSAC). * Corresponding author. Professor P.V. Giannoudis, BSc, MB, MD, FRCS, Department of Trauma and Orthopaedics, Academic Unit, Clarendon Wing, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, LS1 3EX, United Kingdom. Tel.: +44 113 392 2750. E-mail address: [email protected] (P.V. Giannoudis). 0020-1383/ $ – see front matter © 2011 Elsevier Ltd. All rights reserved.
Many approaches have been used in order to identify patients who are infected or colonised with MRSA. To date, however, there have been few studies which detail the cost effectiveness of these methods. Department of Health policy in England now requires that all elective and acute admissions are screened for MRSA; in addition, some high-risk units (e.g. orthopaedic wards) undertake discharge and additional patient screening and staff screening if a single case is detected, and isolation of carriers.13 Glycopeptides are the mainstay of MRSA treatment in the United Kingdom with vancomycin and teicoplanin being the drugs of choice. Both are given parentally, although vancomycin is less well tolerated and the penetration of teicoplanin into bone is better than that of vancomycin. Although teicoplanin can be administered as a bolus dose and can therefore be given on an out-patient basis, both antibiotics are generally regarded as suitable for in-patient treatment. The development of the oxazolidinone linezolid was an important development in the pharmacotherapy of MRSA infection. Linezolid inhibits an early step in protein synthesis and has excellent tissue penetration and 100% bioavailability after oral administration. Linezolid compares favourably with vancomycin, specifically against MRSA causing skin and soft tissue infection.15 Linezolid is recommended as an alternative when conventional therapy has failed or is not tolerated.16 It allows oral, and hence out-patient, administration. However, the apparent increase in side effects, particularly the bone-marrow suppression seen on prolonged administration, means that it should be used under careful observation.17 Pooling the findings from different surveillance programmes, one can obtain a more detailed and reliable picture of the problem posed by MRSA. There was a dramatic rise in the total numbers of cases of S. aureus bacteraemia during the 1990s and also an increase in the proportion of such cases that are associated with MRSA.18 However, most recent data have indicated a reversal of these tendencies.19 Characterisation of isolates of MRSA shows a marked temporal relationship between the rise in MRSA bacteraemias and the emergence and spread of two strains of epidemic MRSA, EMRSA-15 and EMRSA-16. Surveillance and control of MRSA infection continue to be high profile and further developments to the mandatory surveillance system in England are likely in the near future.20 What are the recent epidemiological data however on MRSA infections? In Scandinavia the level of methicillin resistance in S. aureus isolates was found to be <1%, whereas in other countries such as Spain, France and Italy greater than 30% levels were noted.21 Other authors have reported rates between 2% to 58% in different countries within Europe.22,23 The prevalence is estimated to be at least 10% in most European countries.18 De Lucas-Villarrubia et al. showed the prevalence of MRSA to be 1.6% within an
S2
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 42 (2011) S5, S1–S2
orthopaedic department compared with 0.3% within the general hospital setting.24 Tai et al. reported similar results, with 1.6% of the total orthopaedic admissions to a London teaching hospital being either infected with or colonised by MRSA.25 The SENTRY study showed that although the overall numbers of staphylococcal infections within an orthopaedic setting were low in comparison with those in general medicine or intensive care, the level of methicillin resistance was high.22 In a study that was designed to assess the epidemiology of SSI in orthopaedic trauma surgery following acetabular fracture open reduction and internal fixation, the prevalence of MRSA was reported to be 0.9%.26 O’Malley et al.27 examined the prevalence of community-acquired MRSA (CA-MRSA) hand infection in an urban setting. Out of 85 patients studied, the overall prevalence rate of CA-MRSA in hand infections was 55%.27 In a retrospective, multicentre cohort study, out of 504 patients treated for neck of femur fracture, 22 (5.6%) developed SSI, of which 7 were caused by MRSA (1.4%) (32% out of all the bacteria isolated). The authors concluded that SSI after surgery for femoral neck fracture is severe, and MRSA is the most frequently encountered aetiologic pathogen.28 Nixon et al.29 examined the incidence of infection with MRSA in patients admitted in a busy trauma unit over a 3-year period. The influence of MRSA status at the time of their admission was examined, together with age, gender and diagnosis, using multivariant analysis. Of 2473 patients, 79 (3.2%) were MRSA carriers at the time of admission and 2394 (96.8%) were MRSA-negative. Those carrying MRSA at the time of admission were more likely to develop surgical site infection with MRSA (7 of 79 patients, 8.8%) than nonMRSA carriers (54 of 2394 patients, 2.2%, p < 0.001). Further analysis showed that hip fracture and increasing age were also risk factors with a linear increase in relative risk of 1.8% per year. MRSA carriage at admission, age and the pathology were all associated with an increased rate of developing MRSA wound infection.29 In another 5-year prospective study, the impact of MRSA was assessed on an orthopaedic unit. We identified 318 cases of MRSA, representing 0.76% of all admissions (41 971). A total of 240 (76%) cases was colonised with MRSA, and 120 (37.7%) were infected. A total of 115 cases (36.6%) was colonised or infected on admission. The authors concluded that the financial burden of MRSA is increasing, highlighting the need for progress in understanding how to control this resistant pathogen more effectively.30 Overall, from the different studies available in the literature it appears that the incidence of MRSA infection is 1–5% in trauma patients. In this special issue a number of articles have been compiled together to highlight the current issues surrounding MRSA infection in the trauma and orthopaedic and vascular disciplines. We are aware that not all of the important issues can be covered but we hope that this supplement will enhance the clinician’s knowledge on this ever important clinical subject. Competing interests The authors have no conflicts of interest to declare. References 1. Kalra S, Williams A, Whitaker R, Hossain M, Curtis G, Giles M, et al. Subclinical thyroid dysfunction does not affect one-year mortality in elderly patients after hip fracture: a prospective longitudinal study. Injury 2010 Apr;41(4):385–7. 2. Bennet SJ, Berry OM, Goddard J, Keating JF. Acute renal dysfunction following hip fracture. Injury 2010 Apr;41(4):335–8. 3. Matharu GS, Porter KM. Timing of surgery for hip fractures. Injury 2010 Jul; 41(7):1060–1.
4. Najran PS, Matharu GS, Porter KM. Non-operative treatment following hip fracture. Injury 2010 Jul;41(7):1062–3. 5. Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS. Surgical site infection in the elderly following orthopaedic surgery risk factors and outcomes. J Bone Joint Surg Am 2006;88:1705–12. 6. Pollard TCB, Newman JE, Barlow NJ, Price JD, Willett KM. Deep wound infection after proximal femoral fracture: consequences and costs. J Hosp Infect 2006;63: 133–9. 7. Parker MJ, Stedtfeld HW. Internal fixation of intracapsular hip fractures with a dynamic locking plate: initial experience and results for 83 patients treated with a new implant. Injury 2010 Apr;41(4):348–51. 8. Roy L, Laflamme GY, Carrier M, Kim PR, Leduc S. A randomised clinical trial comparing minimally invasive surgery to conventional approach for endoprosthesis in elderly patients with hip fractures. Injury 2010 Apr;41(4): 365–9. 9. Parker MJ, Ali SM. Short versus long thread cannulated cancellous screws for intracapsular hip fractures: a randomised trial of 432 patients. Injury 2010 Apr; 41(4):382–4. 10. Parker MJ, Pryor G, Gurusamy K. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures: a long-term follow-up of a randomised trial. Injury 2010 Apr;41(4):370–3. 11. Malizos KN, Gougoulias NE, Dailiana ZH, Varitimidis S, Bargiotas KA, Paridis D. Ankle and foot osteomyelitis: treatment protocol and clinical results. Injury 2010 Mar;41(3):285–93. 12. Megas P, Saridis A, Kouzelis A, Kallivokas A, Mylonas S, Tyllianakis M. The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method. Injury 2010 Mar;41(3):294–9. 13. Giannoudis PV, Parker J, Wilcox MH. Methicillin-resistant Staphylococcus aureus in trauma and orthopaedic practice. J Bone Joint Surg Br 2005;87-B:749–54. 14. Jevons MP. Celbenin-resistant staphylococci. Br Med J 1961;1:124–5. 15. Wilcox MH. Efficacy of linezolid versus comparator therapies in Gram-positive infections. J Antimicrob Chemother 2003;51(Suppl 2):27–35. 16. Cepeda JA, Whitehouse T, Cooper B, Hails J, Jones K, Kwaku F, et al. Linezolid versus teicoplanin in the treatment of Gram-positive infections in the critically ill: a randomized, double-blind, multicentre study. J Antimicrob Chemother 2004; 53:345–55. 17. Harwood PJ, Giannoudis PV. The safety and efficacy of linezolid in orthopaedic practice for the treatment of infection due to antibiotic-resistant organisms. Expert Opin Drug Saf 2004;3:405–14. 18. European Antimicrobial Resistance Surveillance System (EARSS). http://www.earss.rivm.nl (accessed 14/12/10). 19. Health Protection Agency. Mandatory bacteraemia surveillance scheme 2004. 20. Johnson AP, Pearson A, Duckworth G. Surveillance and epidemiology of MRSA bacteraemia in the UK. J Antimicrob Chemother 2005 Sep;56(3):455–62. 21. Voss A, Milatovic D, Wallrauch-Schwarz C, Rosdahl VT, Braveny I. Methicillinresistant Staphylococcus aureus in Europe. Eur J Clin Microbiol Infect Dis 1994;13: 50–5. 22. Fluit AC, Wielders CL, Verhoef J, Schmitz FJ. Epidemiology and susceptibility of 3,051 Staphylococcus aureus isolates from 25 university hospitals participating in the European SENTRY study. J Clin Microbiol 2001;39:3727–32. 23. Jones ME, Karlowsky JA, Draghi DC, Thornsberry C, Sahm DF, Nathwani D. Epidemiology and antibiotic susceptibility of bacteria causing skin and soft tissue infections in the USA and Europe: a guide to appropriate antimicrobial therapy. Int J Antimicrob Agents 2003;22:406–19. 24. De Lucas-Villarrubia JC, Lopez-Franco M, Granizo JJ, De Lucas-Garcia JC, GomezBarrena E. Strategy to control methicillin-resistant Staphylococcus aureus postoperative infection in orthopaedic surgery. Int Orthop 2004;28:16–20. 25. Tai CC, Nirvani AA, Holmes A, Hughes SP. Methicillin-resistant Staphylococcus aureus in orthopaedic surgery. Int Orthop 2004;28:32–5. 26. Suzuki T, Morgan SJ, Smith WR, Stahel PF, Gillani SA, Hak DJ. Postoperative surgical site infection following acetabular fracture fixation. Injury 2010 Apr; 41(4):396–9. 27. O’Malley M, Fowler J, Ilyas AM. Community-acquired methicillin-resistant Staphylococcus aureus infections of the hand: prevalence and timeliness of treatment. J Hand Surg Am 2009 Mar;34(3):504–8. 28. Merrer J, Girou E, Lortat-Jacob A, Montravers P, Lucet JC; Groupe de Recherche sur l’Antibioprophylaxie en Chirurgie. Surgical site infection after surgery to repair femoral neck fracture: a French multicenter retrospective study. Infect Control Hosp Epidemiol 2007 Oct;28(10):1169–74. 29. Nixon M, Jackson B, Varghese P, Jenkins D, Taylor G. Methicillin-resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J Bone Joint Surg Br 2006 Jun;88(6):812–7. 30. Roche SJ, Fitzgerald D, O’Rourke A, McCabe JP. Methicillin-resistant Staphylococcus aureus in an Irish orthopaedic centre: a five-year analysis. J Bone Joint Surg Br 2006 Jun;88(6):807–11.