Methicillin-Resistant Staphylococcus Aureus (MRSA)

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Methicillin-Resistant Staphylococcus Aureus (MRSA)

• Presented by
• Sandi Henley RN, CIC
• Texas Department of State Health Services, Region
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Staphylococcus aureus

• Staphylococcus aureus, often referred to simply
  as "staph," are bacteria commonly carried on the
  skin or in the nose of healthy people.

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Staph and More Staph

• Staphylococcus aureus The staph bacteria are one
  of the most common causes of skin infections in
  the United States
• Most of these skin infections are minor (such as
  pimples and boils) and can be treated without
  antibiotics (also known as antimicrobials or
  antibacterials).

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Staphylococcus aureus

• However, staph bacteria also can cause serious
  infections (such as surgical wound infections,
  bloodstream infections, and pneumonia).

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Staphylococcus aureus

• Approximately 25 to 30 of the population is
  colonized (when bacteria are present, but not
  causing an infection) in the nose with staph
  bacteria.

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Staphylococcus aureus THE SUPER BUG

• Methicillin-resistant Staphylococcus aureus
  (MRSA)
• HA-MRSA refers to Hospital (or Healthcare)
  Acquired Methicillin Resistant Staphylococcus
  aureus which occurs in a hospital or other
  healthcare related institution or in individuals
  receiving healthcare (ie dialysis) on an ongoing
  basis
• Increasingly important cause of
  healthcare-associated infections since 1970s
• CA-MRSA refers to Community Acquired
  Methicillin Resistant Staphylococcus aureus which
  occurs in individuals that are normally healthy
  and not receiving healthcare on an ongoing basis
  for chronic conditions
• In 1990s, emerged as cause of infection in the
  community

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MRSA

• While 25 to 30 of the population is colonized
  with staph
• approximately 1 is colonized with MRSA.

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Not a new SUPERBUG

• As shown on previous slides been around since
  the 1970s
• Community acquired MRSA became more prevalent in
  the 1990s

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The following is an excerpt from TIME Magazine -
Time - Sep 12, 1960

• Too sick even to cry, the tiny, four-week-old
  infant lay limply on its bed in a British
  hospital Tests of blood and pus samples, drawn
  from an inflamed abscess on the child's right
  hip, produced a chilling diagnosis
  Staphylococcus aureus, of the dreaded "hospital
  type," which is resistant to penicillin and most
  antibiotics. With little hope of success,
  physicians administered massive doses of
  penicillin and streptomycin. Neither worked, and
  the child hovered near death.
• This was an example of staph that was resistant
  to penicillin a very dreaded event at the time.
  As an aside, the child did survive after being
  given a new antibiotic which was a ß-lactam
  type still being tested.

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Why are we seeing MRSA

• After the event of pencillinase producing Staph
  aureus or a resistant form of Staph- in the 50
  and 60s, physicians begin using the ß-lactam
  antibiotics. Methicillin is a ß-lactam
  antibiotic
• It didnt take many years for resistance to these
  ß-lactam antibiotics to emerge.
• This was the beginning of MRSA.

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Time required for prevalence rates of resistance
to reach 25 in hospitals
Emerging Infectious Diseases, Vol 7, No 2,
Mar-Apr 2001 The Changing Epidemiology of
Staphylococcus aureus? Henry F. Chambers
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December 16, 1993 Community-Acquired
Methicillin-Resistant Staphylococcus aureus
Infection

• To the Editor We report a community-acquired
  methicillin-resistant Staphylococcus aureus
  infection in a 65-year-old woman who did not use
  intravenous drugs and was not a nursing home
  resident. The patient was hospitalized with
  endocarditis due to methicillin-resistant S.
  aureus. Neither she nor her husband had been
  hospitalized for the past 15 years. They had not
  visited a nursing home. No family members worked
  in a health care facility, and none used
  intravenous drugs. She became deaf, quadriplegic,
  and aphasic as a result of the infection and its
  treatment.
• Cells for culture were obtained from the hands,
  nose, and throats of family members, including
  the husband, two daughters, and two
  grandchildren. Methicillin-resistant S. aureus
  was isolated from the nose of a five-year-old
  grandson, who lived one block away. Six months
  later methicillin-resistant S. aureus was again
  isolated from the grandson. It was not found 18
  months later.
• 
  .
• We do not know the extent of colonization with
  methicillin-resistant S. aureus in the community.
  We hope that this case is an isolated one.

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Who gets staph or MRSA infections?

• Staph infections, including MRSA, occur most
  frequently among persons in hospitals and
  healthcare facilities (such as nursing homes and
  dialysis centers) who have weakened immune
  systems. These healthcare-associated staph
  infections include surgical wound infections,
  urinary tract infections, bloodstream infections,
  and pneumonia.

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What is community-associated MRSA (CA-MRSA)?

• Staph and MRSA can also cause illness in persons
  outside of hospitals and healthcare facilities.
• MRSA infections that are acquired by persons who
  have not been recently (within the past year)
  hospitalized or had a medical procedure (such as
  dialysis, surgery, catheters) are known as
  CA-MRSA infections.
• Staph or MRSA infections in the community are
  usually manifested as skin infections, such as
  pimples and boils, and occur in otherwise healthy
  people.

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Risk Factors
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CA-MRSA Infections are Mainly Skin Infections
Fridkin et al NEJM 20053521436-44
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Most Invasive MRSA Infections Are
Healthcare-Associated
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Klevens et al JAMA 20072981763-71
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Incidence of Invasive CA-MRSA Infections and
Deaths by AgeActive Bacterial Core surveillance
(ABCS), 2005
Incidence per 100,000 persons
Overall Incidence (all ages) Infections 4.6 per
100,000 Deaths 0.5 per 100,000
Klevens et al JAMA 20072981763-71
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Types of CA-MRSA Infections

• Furuncles
• Impetigo
• Scalded Skin Syndrome
• Necrotizing soft tissue infections
• Septic arthritis/osteomyelitis
• Pneumonia
• Endocarditis
• Toxic Shock Syndrome

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HA-MRSA /CA-MRSA

• HA-MRSA
• Age mean 68
• Underlying disease 76
• Skin and Soft tissue 37
• Respiratory tract 22

• CA-MRSA
• Age mean 23
• Underlying disease 15
• Skin and Soft tissue 75
• Respiratory tract 6

Naimi TS et al. JAMA, 2003, 2902976-2984
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Community-Associated MRSACDC Population-Based
Surveillance Definition

• MRSA culture in outpatient setting or 1st 48
  hours of hospitalization AND patient lacks risk
  factors for healthcare-associated MRSA
• Hospitalization
• Surgery
• Long-term care
• Dialysis
• Indwelling devices
• History of MRSA

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Outbreaks of MRSA in the Community

• Often first detected as clusters of abscesses or
  spider bites
• Various settings
• Sports participants
• Inmates in correctional facilities
• Military recruits
• Daycare attendees
• Native Americans / Alaskan Natives
• Men who have sex with men
• Tattoo recipients
• Individuals living in Long Term Shelters

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Clinical Considerations - Evaluation

• MRSA should also be considered in differential
  diagnosis of severe disease compatible with S.
  aureus infection
• Osteomyelitis
• Empyema
• Necrotizing pneumonia
• Septic arthritis
• Endocarditis
• Sepsis syndrome
• Necrotizing fasciitis
• Purpura fulminans

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Management of Skin Infections in the Era of
CA-MRSA

• ID should be routine for purulent skin lesions
• Obtain material for culture
• No data to suggest molecular typing or
  toxin-testing should guide management
• Empiric antimicrobial therapy may be needed
• Alternative agents have s and s More data
  needed to identify optimal strategies
• Use local data for treatment
• Patient education is critical!
• Maintain adequate follow-up

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Management of Severe / Invasive Infections

• Vancomycin remains a 1st-line therapy for severe
  infections possibly caused by MRSA
• Other IV agents may be appropriate Consult an
  infectious disease specialist.
• Final therapy decisions should be based on
  results of culture and susceptibility testing
• Severe community-acquired pneumonia Vancomycin
  or linezolid if MRSA is a consideration

IDSA/ATS Guidelines for treatment of CAP in
adults Mandell et al. CID 200744S27-72
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MRSA Symptoms

• Dependant on the part of the body affected.
• Remember most CA-MRSA are infection soft the skin
  or other soft tissue. Look for areas that are
• Swollen
• Red
• Painful
• Pus-filled
• Many people mistake a staph skin infection for a
  spider bite

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OTHER TYPES OF CA-MRSA INFECTIONS

• Staph that infects the lungs and causes pneumonia
  can lead to
• Shortness of breath
• Fever
• Chills
• Not limited to CA-MRSA all staph aureus can
  cause pneumonia
• Staph Pneumonia represents a relatively rare
  phenomenon.

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Appropriate Antibiotic Use
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This video was produced in partnership with
Kaiser Permanente

• Talking with Patients About Antibiotic Use An
  Interaction Model
• This video displays a conversation between a
  healthcare provider and a patient. the physician
  explains to the patient the difference between
  bacteria and virus and why colds are not treated
  with antibiotics.

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Should Schools Close?

• This decision will be made by school officials in
  consultation with local and/or state public
  health officials
• However, in most cases, it is not necessary
  because of a MRSA infection in a student

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Should the school notify parents for each MRSA
infection?

• Usually, it should not be necessary to inform the
  entire school community about a single MRSA
  infection
• HOWEVER the school should be notified of a
  students MRSA infection so that appropriate
  steps can be taken to help prevent the spread of
  germs.
• Remember MRSA can be prevented by SIMPLE MEASURES
  such as hand hygiene and covering infections

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SUMMARY

• New strains of MRSA have emerged in the
  community, with implications for management of
  skin infections and other staphylococcal
  infections.
• Incision and drainage remains a primary therapy
  for purulent skin infections.
• Oral treatment options are available for patients
  with skin infections that require ancillary
  antibiotic therapy.
• Patient education on proper wound care is a
  critical component of case management for
  patients with skin infections.
• Strategies focusing on increased awareness, early
  detection and appropriate management, enhanced
  hygiene, and maintenance of a clean environment
  have been successful in controlling clusters /
  outbreaks of infection.

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Scenarios - Skin Lesions

• You have a student in your classroom with a large
  boil on his forearm. What, if any actions,
  should you take?
• In a classroom (or other study body, i.e. team)
  of fifteen, nine students have pustular skin
  lesions. What actions should you take?

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Scenario Staph Pneumonia

• It is Wednesday afternoon and Janna is a student
  at your school is has became ill. Her parents
  picked her up from school and she was later
  hospitalized that day.
• Thursday morning rumors are rampant that Janna is
  near death. Unfortunately, these rumors are well
  founded as she expires that afternoon.
• The parents who are friends with the school
  secretary have said that the physician thought
  she died from staphylococcal pneumonia.

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Scenario Staph Pneumonia

• Should the school close?
• Did she get it from her classmate with the
  pimple
• The teacher down the hall is concerned about
  coming to work as she is pregnant -what do you
  tell her?Do you need to disinfect the room?
• She was on an athletic team - what should be done
  about that?
• Why didnt the school close when they had that
  football player with the infection?
• Do you send a letter to the parents about
  precautions they should take?

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Questions?