Methicillin-Resistant Staphylococcus Aureus Infection Following Arthroscopy of the Knee Joint

Abstract

Arthroscopic surgery of the knee is considered to be a safe procedure. We had a microbiologically confirmed infection of methicillin-resistant Staphylococcus aureus (MRSA). Although various rare infective cases are reported following arthroscopy of the knee joint, to the best of our knowledge there is no previous report of MRSA infection following arthroscopy of the knee joint.

Arthroscopic surgery of the knee joint is one of the commonest orthopaedic procedures. Infection following the arthroscopic surgery is rare. The incidence of infection varies from 0.01% to 0.48%.¹ We believe that this is the first report of methicillin-resistant Staphylococcus aureus (MRSA) infection following arthroscopic surgery of the knee joint.

Case report

A 32-year-old female health care worker (staff nurse) had a right knee arthroscopy for a symptomatic knee joint 5 years after an anterior cruciate ligament reconstruction. Nine days postoperatively, she presented to accident and emergency with an ectopic pregnancy. A minilaparotomy was done as an emergency procedure. Fifteen days after the arthroscopic procedure, she presented to the accident and emergency department with a painful swollen knee. There was marked effusion in the knee and the range of movements was reduced. The patient had mild pyrexia (37.5°C). Blood cultures proved negative. A cloudy green fluid was aspirated from the knee joint, the microscopy of which revealed 70% polymorphs and Gram-stain was negative. Her inflammatory markers were markedly raised (ESR 44 mm/h [normal 1–12 mm/h], CRP 91.1 mg/l [normal < 5 mg/l]). She was immediately commenced on intravenous antibiotics (benzyl penicillin 1.2 g and flucloxacillin 1 g, 6-hourly each) and was admitted for arthroscopic washout of the knee. This was repeated 2 days later. The fluid from the knee was sent for culture and sensitivity. The initial culture report was negative but the enrichment culture grew MRSA 9 days after the arthroscopic washout. At this stage, we changed the antibiotic therapy to intravenous teicoplanin (400 mg every 12 h for 3 doses followed by 400 mg daily). She continued this treatment via a home-managed PIC line. She had complete recovery in 6 weeks. She underwent MRSA eradication protocol and ultimately, became MRSA negative.

Discussion

The rate of infection following arthroscopic surgery of the knee joint varies between 0.01 to 0.48%.¹ Staphylococcus spp. are the commonest organism (75.8%) following arthroscopic surgery.² Other organisms include Streptococcus spp. (5.7%) and Pseudomonas spp. (2.3%). There are case reports of Herpes simplex infection,³ Pseudomonas aeruginosa, Clostridium perfringens and Neisseria meningitides. Wind et al.⁴ reported a case of Candida albicans infection following arthroscopy.

Healthcare professionals are more prone to colonise with MRSA. In this case, there is a possibility of acquiring MRSA following the gynaecological surgery as well. Despite the severe clinical features, the causative organism proved hard to identify initially. A 6-week course of intravenous teicoplanin via a home-use PIC line proved a well-tolerated and completely effective treatment with no sequelae.

It is our hospital policy to screen for MRSA carriage in all elective orthopaedic procedures and those found to be positive for MRSA are administered a 5-day decolonisation protocol followed by repeat screen swabs for eradication.⁵ Emergency admissions, however, will cause a breach of this protection.