Methicillin-resistant Staphylococcus aureus in hip fracture

Bone Joint J. 2021 Jan;103-B(1):170-177. doi: 10.1302/0301-620X.103B1.BJJ-2020-0659.R1.


Aims: Infection after surgery increases treatment costs and is associated with increased mortality. Hip fracture patients have historically had high rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization and surgical site infection (SSI). This paper reports the impact of routine MRSA screening and the "cleanyourhands" campaign on rates of MRSA SSI and patient outcome.

Methods: A total of 13,503 patients who presented with a hip fracture over 17 years formed the study population. Multivariable logistic regression was performed to determine risk factors for MRSA and SSI. Autoregressive integrated moving average (ARIMA) modelling adjusted for temporal trends in rates of MRSA. Kaplan-Meier estimators were generated to assess for changes in mortality.

Results: In all, 6,189 patients were identified before the introduction of screening and 7,314 in the post-screening cohort. MRSA infection fell from 69 cases to 15 in the post-screening cohort (p < 0.001). The ARIMA confirmed a significant reduction in MRSA SSI post-screening (p = 0.043) but no significant impact after hand hygiene alone (p = 0.121). Overall SSI fell (2.4% to 1.5%), however deep infection increased slightly (0.89% to 1.06%). ARIMA showed neither intervention affected overall SSI ("cleanyourhands" -0.172% (95% confidence interval (CI) -0.39% to 0.21); p = 0.122, screening -0.113% per year, (95% CI -0.34 to 0.12); p = 0.373). One-year mortality after deep SSI was unchanged after screening (50% vs 45%; p = 0.415). Only warfarinization (OR 3.616 (95% CI 1.366 to 9.569); p = 0.010) and screening (OR 0.189 (95% CI 0.086 to 0.414); p < 0.001) were significant covariables for developing MRSA SSI.

Conclusion: While screening and decolonization may reduce MRSA-associated SSI, the benefit to patient outcome remains unclear. Overall deep SSI remains an unsolved problem that has seen little improvement over time. Preventing other hospital-associated infections should not be forgotten in the fight against MRSA. Cite this article: Bone Joint J 2021;103-B(1):170-177.

Keywords: Hip fracture; MRSA; Screening; Surgical site infection.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cross Infection / microbiology*
  • Cross Infection / mortality
  • Cross Infection / prevention & control
  • Female
  • Hand Hygiene
  • Hip Fractures / mortality
  • Hip Fractures / surgery*
  • Humans
  • Male
  • Methicillin-Resistant Staphylococcus aureus*
  • Risk Factors
  • Staphylococcal Infections / microbiology*
  • Staphylococcal Infections / mortality
  • Staphylococcal Infections / prevention & control
  • Surgical Wound Infection / microbiology*
  • Surgical Wound Infection / mortality
  • Surgical Wound Infection / prevention & control