Hospital Survey On MRSA Reveals Obstacles And Potential Solutions

With the incidence of methicillin-resistant Staphylococcus aureus rising, how can healthcare institutions protect patients? The Association for Professionals in Infection Control and Epidemiology (APIC) recently conducted a survey of 1,237 hospitals and has formulated recommendations for preventing MRSA transmission.

The study noted the rate of MRSA was 46 in 1,000 patients. Of those patients, 34 in 1,000 patients were infected and 12 in 1,000 patients were colonized.

The APIC emphasizes the importance of good hand hygiene, including frequent hand washing, alcohol-based hand rubs and the use of gloves. Mark Kosinski, DPM, advises washing one’s hands before and after seeing each patient.

“Many people underestimate the importance of such a simple act,” points out Dr. Kosinski, a Professor in the Department of Medicine at the New York College of Podiatric Medicine. “As part of a recent infection control surveillance study in a New York City hospital, about 60 percent of hospital personnel were observed to wash their hands before and after each patient contact.”

Addressing The Barrier Of Preventive Costs
Another APIC recommendation is placing patients with MRSA in private rooms and using gloves, gowns and other precautions to avoid transferring microorganisms to other patients or environments.

Peter Wilusz, DPM, concedes that cost is a significant barrier when it comes to isolating patients who are diagnosed with any form of resistant bacteria. However, the APIC notes that an analysis of 55 studies found that the cost of treating hospital-acquired MRSA was $35,367 in comparison to $13,973 for treating other hospital-acquired infections.

“It is important to demonstrate to (hospital) administrators that costs of the intervention can indeed be less than the cost of not adopting a MRSA control program,” notes the APIC.

Healthcare institutions should also follow proper environmental and equipment cleaning and decontamination, recommends the APIC, which also emphasizes the importance of educating environmental and housekeeping staff on correct cleaning procedures since MRSA “can survive outside the human body for up to 56 days on patient charts, tabletops and cloth curtains.”

Emphasizing The Appropriate Use Of Cultures And Antibiotics
The APIC recommends changes in hospital culture and Dr. Kosinski says the two biggest barriers in hospitals are “habit and complacency.” For example, he says DPMs know that the overuse of antibiotics fuels resistance “yet time and again, we see so-called prophylactic antibiotics being used in clean orthopedic surgery. The patient is sent home with a prescription for Keflex after a bunion or hammertoe procedure to ‘prevent infection,’” says Dr. Kosinski, a member of the Infectious Diseases Society of America (IDSA).

Further, Dr. Kosinski says the complacency “is rooted in the belief that the drug companies will discover new antibiotics to bail us out.”

Calling MRSA prevention “key to all healthcare providers,” Vickie Driver, DPM, advocates that practitioners “reduce and or limit antibiotic usage in the first place.” As an example, she says institutions could use the IDSA guidelines to avoid over-prescribing antibiotics.

Dr. Wilusz cites the problem of healthcare professionals using “cookbook” medicine to treat an infection without appropriate identification through culture and sensitivity. He says some physicians may start with a penicillin and then, seven to 10 days later when the infection is still persistent, switch to another broad spectrum antibiotic such as a quinolone without identifying a bacterial source through culture and sensitivity.

“By the time a culture is taken, a patient may have been on one or two different antibiotics, which may affect the outcome of the culture and sensitivity, and/or generate a resistant bacterial infection through the process,” says Dr. Wilusz, a Clinical and Surgical Instructor at the Foot and Ankle Clinic at the Southeastern Michigan Surgical Hospital.

Concurring with Dr. Wilusz, Dr. Driver says physicians should prescribe antibiotics that are specific to cultures as quickly as possible. (See “An Update On Antibiotics For MRSA” below.) Clinicians should perform cultures via deep tissue curettage, instead of using a superficial swab, in order to avoid treating non-pathogenic organisms, according to Dr. Driver, the Director of Clinical Research at the Center for Lower Extremity Ambulatory Research at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine.

Making The Commitment To Earlier Detection And Prevention
Dr. Wilusz likewise cites the establishment of better education, standard protocols “and a healthy dose of common sense” when hospitals suspect a resistant infection. He advocates instituting standard protocols in cities where high rates of known MRSA levels already exist.

As part of a screening process for patients, he suggests obtaining a nasal swab sample to determine if the patient is a MRSA carrier. Dr. Wilusz says early detection and treatment with Bacitracin nasal ointment may theoretically help reduce the incidence of the growing morbidity and mortality from MRSA infections.

Although hospitals usually have a clear understanding of the literature regarding MRSA infections and follow guidelines set by the Joint Commission on the Accreditation of Healthcare Organizations, Dr. Driver advocates “clearer instructions” and more education on the rise of MRSA outside of the hospital setting. “We need stronger, clearer education modules for clinics, sub-acute care and the home, which is where transmission occurs the most,” she emphasizes.

What A Study Reveals About Chronic Plantar Heel Pain
By Brian McCurdy, Senior Editor

Can increased ankle dorsiflexion be a factor in chronic plantar heel pain? A recent study in BMC Musculoskeletal Disorders claims a link between the two, with researchers noting their conclusion is contrary to the “common clinical perspective” that decreased dorsiflexion is a contributing factor to plantar heel pain.

Researchers studied 80 people with chronic plantar heel pain and 80 people in a control group. The study compared the two groups in regard to body mass index (BMI), foot posture, angle dorsiflexion range of motion (ROM), occupational lower limb stress and calf endurance.

An analysis revealed that those with chronic plantar heel pain had a significantly higher BMI, more pronated foot posture, and more ankle dorsiflexion than the control group, according to the study. Researchers concluded that those with chronic plantar heel pain were more likely to be obese (defined as a BMI > 30 kg/m2) and have a pronated foot posture.

The study identified both obesity and pronation as risk factors for chronic plantar heel pain. The study authors added that decreased ankle dorsiflexion, calf endurance and occupational lower limb stress “may not play a role” in the condition.

Is Increased Ankle Dorsiflexion A Key Factor?
Why was there an association between increased ankle dorsiflexion ROM and chronic plantar heel pain? Study authors cite a possible explanation that there may be a non-linear relationship between ankle dorsiflexion range of motion and plantar fascia strain.

However, Patrick Nunan, DPM, does not agree with the study. He says he has treated patients with chronic plantar heel pain with varying degrees of ankle dorsiflexion.

Dr. Nunan cites a possible flaw in the study in that the researchers used the dorsiflexion lunge test, which relaxes the gastrocnemius muscle. The study also acknowledges that the lunge test does not control for foot pronation or supination.

“As increased subtalar joint pronation is known to increase the amount of dorsiflexion that can occur at the midtarsal joint, it is plausible that the increased ankle dorsiflexion ROM observed in the case group may have been due to the fact that the group was also found to have a more pronated foot posture,” note the study researchers.

Often when patients with chronic plantar fasciitis are evaluated, Dr. Nunan says they may have decreased dorsiflexion when the knee is straight but normal or increased dorsiflexion when the knee is bent. The BMC Musculoskeletal Disorders study notes that authors of previous studies on chronic plantar heel pain examined the patients with the knee extended.

“Since knee extension biases the gastrocnemius muscle whilst knee flexion has a soleus bias, it is possible that tightness in the gastrocnemius muscle may have gone undetected in the case group,” note the study authors.

Dr. Nunan says body weight, shoe type, foot type and the surface for work or activities are factors that contribute to chronic plantar heel pain.

Dr. Nunan says BMI, in particular, is a factor in the sedentary population or in those who work and/or stand on hard surfaces. As Dr. Nunan explains, a higher BMI is associated with more pressure on the foot during gait and stance, which over time leads to a slow overload of the plantar fascia.

Although he notes most patients with chronic plantar heel pain are overweight, Dr. Nunan still sees chronic plantar heel pain in well-conditioned athletes.

“The athletes usually have a quicker, higher peak pressure that will cause the pain,” says Dr. Nunan, a Fellow and Past President of the American Academy of Podiatric Sports Medicine.

New Study Favors Alcohol Injections For Neuromas
By Brian McCurdy, Senior Editor

Alcohol injection is a frequently used option for treating Morton’s neuroma. A recent study in the American Journal of Roentgenology cites a very high rate of success with such injections when guided by sonography.

The prospective study included 101 patients with Morton’s neuroma. Patients had received an average of 4.1 treatments with sonographically guided alcohol injections and the average follow-up was at 21.1 months.

The study noted a technical success rate of 100 percent. Ninety-four percent of patients achieved partial or total improvement of symptoms while 84 percent indicated they were completely pain free, according to the study. According to the study, 30 patients underwent sonography six months after the last injection and researchers noted a 30 percent decrease in neuroma size. They add that no complications occurred.

Researchers also conclude that the results of alcohol injection are “at least comparable” to surgery and add that alcohol injection is associated with less morbidity. They also suggest that clinicians should reserve surgical management for patients with Morton’s neuroma who do not respond to alcohol injections.

Charles Peebles, DPM, has achieved a combined success rate of over 80 percent when treating primary and recurrent neuromas with alcohol injections. He says he treated those patients with three to seven injections, which were given an average of seven to 10 days apart. For patients who do not respond completely and need surgical excision, Dr. Peebles has not seen clinical damage to surrounding tissues from the alcohol injections and has had no delays in healing with any of the procedures following prior alcohol injections.

“I treat a very active athletic population and this technique has allowed these marathoners and Iron Man triatheletes to continue to train and compete in these events without the downtime necessary to heal from a surgical procedure,” says Dr. Peebles, a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Peebles notes several advantages to alcohol injections, including limited downtime, a high success rate and limited recurrence. He also says ultrasound guidance likely makes the injection easier and notes the surgery option is still available for patients. On the other hand, he adds that pain may occur with injections. He also notes that one may miss branches from the adjacent nerves, resulting in a failure of the injection technique.

Ankle Replacement Patients Ready For Post-Op Sports
By Brian McCurdy, Senior Editor

Patients who undergo ankle replacement participate more in sports following replacement surgery, according to an abstract presented at the American Academy of Orthopedic Surgeons’ annual meeting.

The prospective clinical study involved 147 patients with 152 ankles who received total ankle arthroplasty for end-stage osteoarthritis (OA). Their average age was 59.6 years and the mean follow-up was 2.8 years. Of the patients treated, 76 percent had post-traumatic OA, 13 percent had primary OA and 11 percent had systemic OA.

Researchers noted 83 patients reported excellent or good satisfaction while 69 percent of ankles were free of pain. Nine percent of ankles had to be revised. The patients’ overall American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Score improved from 36 points preoperatively to 84 points postoperatively, according to the study. Study authors also noted that patients who were active in sports showed significantly higher AOFAS scores than patients who were not active in sports.

In his clinical experience performing ankle replacement procedures, Mark Feldman, DPM, says patients have participated in more sports following ankle replacement. “The pain is gone so physical activity is much improved,” notes Dr. Feldman, who is in private practice in Miami and is a faculty member of the Podiatry Institute.

After patients receive an ankle implant, Dr. Feldman advises them against performing physical activities that can place an undue stress on the implant. Due to the up and down motion of the foot on a surface, he stresses that diving and mountain biking are prohibited. However, stationary bike riding, golfing, walking or swimming are fine.

The study also breaks down the patients’ sports activities: 53 percent hiked, 46 percent biked, 34 percent swam, 12 percent engaged in “fitness,” 8 percent skied and 6 percent golfed.