Commentary & Perspective

Evidence-Based Medicine and Surgical Decision-Making: MRSA and MSSA Osteomyelitis in Children
Commentary on an article by Kevin L. Ju, MD, et al.: Differentiating Between Methicillin-Resistant and Methicillin-Sensitive Staphylococcus
aureus Osteomyelitis in Children. An Evidence-Based Clinical Prediction Algorithm
David J. Zaleske, MD
Louis Pasteur observed that chance favors only the mind that is prepared. Acup-half-lled corollary is that we all have opportunities
for preparation or improvement, continuously. By successive iterations of retrospective analysis and prospective testing, we, as
physicians and surgeons, can identify best practices for helping patients. To add direction and scientic rigor to this process, the
level of evidence for assertions that are added to the literature is also categorized. We now have the ability to search the literature
rapidly and extensively via the Internet, adding appropriate screens or qualiers to avoid data overload. With use of electronic
health records, we can readily track the adoption of an algorithm (a pathway or guideline) and assess whether it is achieving its
desired effect. Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making
decisions about the care of individual patients.
1
In their article, Differentiating Between Methicillin-Resistant and Methicillin-Sensitive Staphylococcus aureus Osteomy-
elitis in Children, Drs. Ju, Zurakowski, and Kocher have given us the evidence-based process by which they have arrived at a
clinical prediction rule for this common entity in pediatric orthopedics. They have done the heavy lifting for us. In their
retrospective review of 129 children with Staphylococcus aureus osteomyelitis, they found that if the patient had a temperature of
>38C, a hematocrit of <34%, a white blood-cell count of >12,000/mL, and a C-reactive protein level of >13 mg/L, there was a
92% chance that the osteomyelitis was caused by methicillin-resistant Staphylococcus aureus (MRSA). On the basis of such data,
they advanced a treatment protocol for the administration of an antibiotic while culture and sensitivity data were pendingi.e.,
either an antibiotic to which both MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) would be sensitive (vanco-
mycin) or an antibiotic to which only MSSAwould be sensitive. The customary recommendation that cultures be obtained prior
to the administration of any antibiotic remains. Is the result by Ju et al. signicantstatistically and also clinically? The results in
their series were statistically signicant, according to their very methodical analysis. The clinical signicance of their results is
subject to several caveats that the authors themselves note in the Discussion. First, the number of MRSA cases was relatively small
(eleven of the 129 cases of osteomyelitis). Second, the study was not designed to establish whether all of the MRSA was of a single
genotype, so the organisms could have changed during the study period. The ability of Staphylococcus aureus to adapt to its host makes
it a formidable and protean pathogen
2
. Another issue not specically discussed by the authors is that their study was not, in the strictest
sense, designed for surgical decision-making. Decisions regarding surgical drainage may be best directed by imaging, at the present
time by magnetic resonance imaging. The decision regarding antibiotics may be best made in close communication with an Infectious
Disease Service. The predictors identied in this retrospective study will need to be tested prospectively. Even with these cautionary
notes, however, the authors have described a process that can be discussed and tested scientically, as this same group has already done
with septic arthritis.
Nevertheless, the possibility that the entire cup of evidence-based medicine is half-empty should at least be considered. A
recent New England Journal of Medicine (April 14, 2011, Vol. 364, No. 15) included two articles regarding protocols to diminish the
transmission of hospital-based MRSA. The conclusions of the articles were opposite
3,4
. In a commentary on those articles, what
would seem to be the appropriate perspective was added: It will be necessary to change the culture of clinical care.
5
Our general
surgical colleagues are embracing these cultural changes with encouraging results. By changing behaviors as directed by new data,
they have improved operative morbidity for high-risk surgery
6
. Therefore, the cup of evidence-based medicine is at least half-lled
for surgery and surgical decision-making.
Drs. Ju, Zurakowski, and Kocher are to be congratulated for embracing this conscientious approach to decision-making in
orthopaedics. It is a journey, not a destination. Patients and surgeons should all benet from high-quality evidence that we
accumulate, improve on, and apply along the way.
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J Bone Joint Surg Am. 2011;93:e109(1-2) d http://dx.doi.org/10.2106/JBJS.K.00785
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David J. Zaleske, MD*
Orthopedic Service, Gillette Childrens
Specialty Healthcare and Childrens Hospitals
and Clinics of Minnesota, Minneapolis, Minnesota
*The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither
the author nor his institution has had any nancial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that
could be perceived to inuence or have the potential to inuence what is written in this work. Also, the author has not had any other relationships, or engaged in any
other activities, that could be perceived to inuence or have the potential to inuence what is written in this work. The complete Disclosures of Potential Conicts of
Interest submitted by authors are always provided with the online version of the article.
References
1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isnt. BMJ. 1996;312:71-2.
2. Lowy FD. How Staphylococcus aureus adapts to its host. N Engl J Med. 2011;364:1987-90.
3. Huskins WC, Huckabee CM, OGrady NP, Murray P, Kopetskie H, Zimmer L, Walker ME, Sinkowitz-Cochran RL, Jernigan JA, Samore M, Wallace D, Goldmann DA; STAR*ICU
Trial Investigators. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011;364:1407-18.
4. Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky DS, Render ML, Freyberg RW, Jernigan JA, Muder RR, Miller LJ, Roselle GA. Veterans Affairs initiative to
prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med. 2011;364:1419-30.
5. Platt R. Time for a culture change? New Engl J Med. 2011;364:1464-5.
6. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364:2128-37.
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COMMENTARY & PERSPECTI VE
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