Louis Pasteur observed that chance favors only the mind that is prepared. A cup-half-filled 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 scientific 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 qualifiers 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 Osteomyelitis 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 >38°C, a hematocrit of <34%, a white blood-cell count of >12,000/μL, 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 pending—i.e., either an antibiotic to which both MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) would be sensitive (vancomycin) or an antibiotic to which only MSSA would be sensitive. The customary recommendation that cultures be obtained prior to the administration of any antibiotic remains. Is the result by Ju et al. significant—statistically and also clinically? The results in their series were statistically significant, according to their very methodical analysis. The clinical significance 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 pathogen2. Another issue not specifically 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 identified 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 scientifically, 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 opposite3,4. 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 surgery6. Therefore, the cup of evidence-based medicine is at least half-filled 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 benefit from high-quality evidence that we accumulate, improve on, and apply along the way.