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An investigation into the transmission of community associated MRSA:Abstract:Methicillin resistant Staphylococcus aureus (MRSA) is a globally described, at the same time clinically significant pathogen. They were responsible in causing skin and soft tissue infections and were becoming prevalent all over the world. Community associated MRSA (CA- MRSA) is the causative agent for many of the outpatient skin infections and also emerged in the individuals who lacks the classical risk factors for acquiring hospital associated MRSA. The objective of this report was to undergo a detailed analysis on various modes of transmissions of CA- MRSA. They most commonly included sports related CA- MRSA infections, transmission among women, heterosexual transmissions, transmissions among the military personnel and prisoners, familial transmissions, transmissions from parent to offsprings and vice versa. There were different case studies in which the result has been demonstrated. The result obtained showed the prominence of infection and transmissions through person to person contact, skin to skin contact and also through the contaminated equipments. Apart from these sexual contacts also seemed to play a major role in the spreading of the disease. Despite an increasing incidence of CA- MRSA among the public the importance of prevention and education among the community was found to be the best possible way to reduce the transmission rates. The conclusion of this report draws the importance of prevention rather than the cure of the disease.

Introduction:Community associated Methicillin resistant Staphylococcus aureus is a bacterial pathogen which has been reported to cause mild local infection of soft tissue and skin and then lead to severe infection which can also be lethal to the individual (David et al, 2006). This bacterium is a gram positive coccus and a member of micrococcae family. Staphylococcus aureus can be the cause for pneumonia, bacteremia and endocarditis disease that are directly caused by the bacteria themselves. S. aureus can also cause some indirect effects due to the toxins produced by these bacteria which result in toxic shock syndrome and Staphylococcal scaled syndrome (Lowy, 1998). Around 25%- 30% of the people in the world carry the staphylococcus bacterium. (Centers for disease control prevention, 2005). Methicillin resistance in S. aureus was brought about by mec A gene which is responsible for the production of penicillin binding proteins but this is absent in the methicillin susceptible strains of this bacterium. (Enright et al, 2002).Whenever presence of S. aurues is detected the presence of mec A gene is detected with the help of the polymerase chain reaction. There are two different types of MRSA types such as health care associated MRSA (HA-MRSA) which can be defined as the infections seen in the patients with the history of recent hospitalizations &community associated MRSA (CA-MRSA) defines the infections occurring in healthy individuals who has not been hospitalized within a past year. Evolution of Staphylococcus bacteria:This microorganism was involved in the infectious process as early as 1800s.(Chambers et al, 2001) Dr. Alexander Fleming discovered the

antibiotic penicillin in the year 1929 and in 1940 it was first used to treat human diseases.(Kurkowski et al, 2007). Because of the widespread use of penicillinase which was known by the name lactamase, in 1940s started producing penicillin resistant strains. Thus they emerged as Penicillin resistant S. aureus (PRSA) most commonly among the hospitalized patients.(Barber et al, 1948). The bla gene produces lactamase enzymes that confers the ability to prevent the penicillin (PCN) from binding the cell wall precursors.( Wright et al, 1999). Thus they prevent the penicillin from synthesizing the bacterial cell wall. In the year 1960, methicillin which is a semi synthetic penicillinase resistant derivative of penicillin was introduced (Corriere et al, 2008). The pre explained mechanisms of penicillin is important for the development of lactamase resistant antibiotics which includes methicillin, cephalosporins, nafcillin. (Wright et al, 1999). But within a year MRSA also emerged as a new threat in 1961. MRSA can be defined as a strain of S. aureus which expresses resistance to any semi synthetic penicillin i.e. methicillin. In the past decades MRSA has become famous as a multidrug resistant organism of concern in health care settings. (Kurkowski et al, 2007). According to the 2004 data from U.S National Nosocominal Infections Surveillance Systems, around 61% of all S. aureus isolates from intensive care units were methicillin resistant. There are many risk factors associated with HA- MRSA such as staying in intensive care units, prolonged hospitalizations, uses of invasive equipments (i.e dialysis machines and catheters) as well as frequent antibiotic administration. (Lowy et al, 1998). The evolution of MRSA into CA- MRSA in people with traditional healthcare risk factors was discussed in the 1980s with the most concern being its emergence among the drug users through injection. (Sarvoltaz et al,

1982). There are a number of features that differentiate CA- MRSA from the HA- MRSA. These include the pattern produced by pulsed field gel electrophoresis. (Kowalski et al, 2005) as well as the production of special toxin named Panton Van Leukcocidin which encodes the pore forming protein involved in the invasion of immune system. In-order to study about the various isolates of S. aureus. DNA cleavage is tested with several enzymes was run on a gel and thereby can be obtained. This procedure was similar to DNA finger printing. Community associated MRSA:CA- MRSA can be explained as the bacterial infection in the people who lack established risk factors associated with HA- MRSA. (Harris et al, 2010). The profiles of the people affected by CA- MRSA and HA- MRSA varies. CAMRSA as the name denotes, occurs in the community and appears in individuals who are otherwise healthy and usually have not been hospitalized for long time. CA- MRSA disease is specifically seen in certain groups of people such as military personal, sports team members, prison inmates, children in daycare facilities, family members etc. (Jernigan et al, 2007 & Daum et al, 2007). These infections were also detected in specific populations such as Alaskans, Native Americans, Pacific Islanders, hetero sexual men and frequent drug users. Other contributing factors for the transmission of this CAMRSA are found to be lack of personal hygiene, dense living conditions, lack of healthcare availability and sharing of personal items. (Graffunder et al, 2002). Colonization of MRSA:-

Colonization is the presence of the micro organism in the body with the absence of clinical syndromes and symptoms of infections such as pustules, swelling, or fever. (Creech et al, 2005). Based on the study of large populations, usually the MRSA colonization rate ranges between 0.26% and 9.2%, but these figures depend on the characteristics of the population. (Creech et al, 2005 & Graham et al, 2006). According to the recent data from the National Health and Nutrition Examination Survey of 2001- 2002, the prevalence of methicillin sensitive strains of S. aureus is 31.6%. Colonization among which 0.84% of people in the survey were affected ones. (Graham et al, 2006). Various studies have shown that the MRSA may remain in the body for prolonged period after colonization. (Sanford et al, 2001). The prolonged bacterial colonization has associated risk factor which includes skin breakage and history of using fluroquinolone. It was found out that the individuals who live along with the MRSA affected individuals are 7 times likely to get colonized when compared to the community connections. (Calfee et al, 2003). Various datas suggests that the nasal colonization is less important in the case of the CA- MRSA. The unexpected origins of CA- MRSA:The strains of CA- MRSA were first believed to be nosocominal strains that had transmitted from the hospital settings to the community. The contradictory sensitivity of CA- MRSA to non lactam anti-microbial agents and related clinical syndromes of MRSA suggest the fact that CA- MRSA is entirely different from the strains which are prevalent in the health care settings. (Herold et al, 2003). Later on the further findings about the genotypic variances between the HA and CA- MRSA gives the hint that CA- MRSA had

evolved from the susceptible strains of the S. aureus bacteria. (Susan et al, 2007). There are three major factors that differentiate CA- MRSA from HAMRSA strains. 1) genetic lineage, 2) the presence of the pvl gene and 3) the architecture of the genetic elements of methicillin resistance. (Susan et al, 2007). Resistance against methicillin can be conferred by acquiring the penicillin binding protein known by the name PBP2a which is a peptidoglycan transpeptidase which is encoded by the mec A gene and it has less affinity towards lactam antimicrobials. (Susan et al, 2007). When the peptidoglycan synthases (i.e. the penicillin binding proteins numbered from I-IV) are bound and inactivated by lactam antibiotics, it is still possible for the PBP2a to achieve cell wall synthesis. mecA is maintained in the Staphylococcal chromosome cassette mec, and this is a genetic element that can be horizontally transferred and integrate site specifically into the chromosome of S. aureus. (Ito et al, 2004). A notable feature of CA- MRSA is the presence of integrated bacteriophage which carries pvl genes. (Vandenesch et al, 2003). The pvl gene is commonly associated with the presence of SSCmec IV and the absence of I, II & III. pvl toxin i.e. Panton Valentine Leukocidin toxin , and its biological and genetical actions have been characterized and organized well. In short, this toxin helps in the leukocyte destruction as well as leading to tissue necrosis at the same time they are also responsible for the greater amount of pus formation. (Lina et al, 1999). Other methods that are used to define the differences between CA- MRSA and HA- MRSA include multilocus sequence typing (MLST) and pulse typing with pulsed field gel electrophoresis. (PFGE). Multilocus sequence typing was proposed in the year 1998. They are universal and portable method used for the characterization of

bacteria, especially S. aureus. (Maiden et al, 2006). This method is very important in clinical microbiology as well as public health because it provides data for the epidemiological surveillance and development of vaccine policy. (Sullivan et al, 2011). PFGE is a powerful tool used for the characterization of various strains at DNA level, with the relevant informations regarding genome size, physical and genetic map of bacterial chromosome. PFGE has got an excellent ability for the separation of small and linear natural chromosomal DNAs. The greater advantage is examining the elongated as well as oriented configuration of the huge DNA molecule. (Basim et al, 2001). It has been found that CA- MRSA isolates vary by geographic location. (Vandenesch et al, 2003) and different genetic backgrounds can also exist in a small geographic location. (Daum et al, 2002). According to the accepted rules explaining the origin of CA- MRSA, a small methicillin resistance cassette was independently integrated into the genomes of various methicillin susceptible S. aureus parent clones that are circulating in various locations. There is a chance that CA- MRSA might have originated from an MSSA which carries pvl gene. (Moran et al, 2006). In some places, the pvl locus seems to be more common among the isolates of CA- MRSA than the susceptible bacterial isolates which suggests that methicillin might have contributed to the success of the pvl positive strains of S. aureus. (Moran et al, 2006). Recently there was a worldwide emergence of diverse strains of similar genetic background which carried both lysogenic phage carrying pvl as well as one among the small methicillin resistance cassette which suggests a common global selection pressure. (Susan et al, 2007). Alarming use of antimicrobials among the public cannot explain the prevalence of the pvl toxin determinant in

CA- MRSA isoalates. It is still doubtful that the SLT and small SSCmec particles share the same vehicle for the purpose of horizontal transfer as they assimilate into well defines sites in the chromosome of S. aureus. The fact that the pvl are able to cause dermonecrosis. (Ward et al, 1980). pvl supplies a selective advantage for the circulation of CA- MRSA among the perfectly healthy population by producing open skin abrasion in the parents. (BoyleVavra et al, 2005). This makes it easier for the bacteria for transmission among the ones who are in close contacts. As per the isolation of pvl negative MRSA from the nostrils of asymptomatic carriers gives the idea that pvl is not essential for the dissemination by the respiratory pathways. (Boyle- Vavra et al, 2005). Clinical presentation of CA- MRSA:The CA- MRSA infections dont have a specific and easily recognizable clinical presentation. The clinical manifestations are skin and soft tissue infection which includes abscesses, boils, bumps, furuncles, and carbuncles which can have other causes than CA- MRSA, including MSSA infection. (Borlaug et al, 2009). Typically the MRSA skin lesions are present as one or more pustules which is most probably surrounded by edema that may be often tender. More than 75% of skin and soft tissue infections are caused by the CAMRSA. (Naimi et al, 2003). The proper diagnosis should be done regarding the skin infections, culture and test all the pus and the impurities which are filled inside the pustule. Outpatient infections from the CA- MRSA are usually mild infections which appear as slight reddish bumps similar to a spider bite. (Borlaug et al, 2009). Severe causes of MRSA present with deep abscesses that requires antibiotics, hospitalization, and surgical treatments. Even-though

CA- MRSA infections are present in a relatively healthy population, they are associated with predominant skin and soft tissue infections as well as severe pulmonary infections which include fatal necrotizing pneumonia and empyema. Reports in 1999 off the deaths of healthy children led to S. aureus as being classified as a virulent pathogen, (CDC, 1999). Initially, it was believed that the key virulence factor in CA- MRSA that contributed to the associated death rate and morbidity was the pvl toxin. Tissue necrosis is the major patho-physiological process in CA- MRSA, even though there are some questions being raised about pvl and the virulence effects according to a recent study. (Voyich et al, 2006). There is a need of a detailed study to understand more about the patho-physiological features that have not yet been discovered. Mechanisms of antibiotic resistance in CA- MRSA:The mechanism of anti biotic resistance in CA- MRSA is somewhat similar to HA- MRSA. Antibiotic resistance is conferred either from the organism or as a response to the chromosomal mutation due to the anti microbial pressures. S. aureus can horizontally acquire the mec gene, responsible for acquired resistance to methicillin. PBP2a production is facilitated by mec gene and it is carried on SCCmec, Staphylococcal cassette chromosome which is a genetic element. PBP2a is involved in strengthening of the cell wall and blocks the lactam binding site by increasing its resistance. (Ito et al, 2001). Presently there are five mec types starting from I- V based on DNA sequencing. Resistance is provided to the antibiotics i.e. lactam by the SCCmec I, II, III and genetic elements. SCCmec type IV and V dont confer the same resistance level to multiple antibiotics as type I, II, & III and are also similar in size (15kb) and are easily transferred to different S. aureus (Daum et al, 2002). The

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predominant SCCmec in CA- MRSA is type IV. Recently there have been reports of CA- MRSA infection within hospitals. SCCmec type IV has a higher sensitivity to non lactam antimicrobials (Baba et al, 2002), but at the same time it is considered as highly virulent as pvl producing strains. Among the community setting, various outbreaks of MRSA infection have been reported in the individuals who are lacking associated risk factors for the acquisition of HA- MRSA. (Boyce et al, 1998). In the hospital most usually MRSA are transmitted through direct and indirect contacts and also the airborne transmission and through droplets has also been reported in healthcare workers. (Sherehtz et al, 2001). In order to reduce the prevalence and transmission of CA- MRSA in the hospitals, the authorities have taken major control measures. These include disinfection of contact surfaces, earlier detection of carriers as well as de- contamination. (Bootsma et al, 2006). The most common mode of transmission of the disease is through the direct contact. Colonization of the bacteria is meant to show the presence of the organism but without causing any infection. Sometimes they are able to cause infection also. Researchers have come across the fact that the colonization of S. aureus proceeds with MRSA infection. Most favorable and common site of colonization of bacteria is the anterior part of the nostrils. (Gorwitz et al, 2007). When colonization occurs in various sites of the body which includes cuts, wounds or groin and the carrier status tend to be persistent with increased rates of transmission. (Kluytmans et al, 1997). CA- MRSA colonization risk factors, including prior antibiotic use, previous bacterial infections, sharing personal materials such as bath towels, and razors, close personal and sexual contact with the person suffering from MRSA, participating in close contact

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sports and games, obese conditions, unhygienic atmospheres, and any skin infections that may allow MRSA bacteria to grow on the body. (Cook et al, 2007). When the carrier status has been confirmed, there is no proper recommendation for treating asymptomatic carriers. The decolonization procedure used for individuals affected in hospitals has succeeded in eliminating CA- MRSA on outpatients temporarily, but most often recolonization of bacteria is reported and a standardized way of decolonization has not yet been implemented. (Harbarth et al, 2000). The therapies which were previously used include antiseptic skin washes containing chlorohexidine components and topically applied nasal mupirocin (which is an antibiotic). They can be initiated with or without the help of antibiotic treatment, but chances of success varies and most of the parents are re- colonized within 3- 6 months of taking the medication. (Laupland, 2003). In addition to the nares, the vagina also tends to be a reservoir for the CA- MRSA. (Chen et al, 2006). Women should be careful when they have contact with genital warts or pustules. (Graffunder et al, 2002). Even if carrier status has been confirmed by vaginal cultures, there is no option available at present for de-colonization, although a combined oral and topical antibiotic therapy may reduce the transmission rate. (Simor et al, 2007). 2% clindamycin vaginal gel is a promising medication for the elimination of vaginal colonization. Even though further progresses are needed to find out a regimen. (Reichman and sobel, 2009).

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CA- MRSA as an important clinical problem:CA- MRSA as an epidemic rendered lactam antibiotic unsuitable for therapeutic purposes, although once they were effective and widely used against S. aureus infections. Although CA- MRSA more often tend to be exposed to non lactam anti-biotics, they are more virulent than HA- MRSA. (Harold et al, 1997). Most of the CA- MRSA is associated with the skin and soft tissue infections. But sometimes the infection rapidly progresses and leads to life threatening diseases such as pneumonia, necrotizing fasciitis and severe bacteremia. (Aden et al, 2005). Severe bacteremia related with necrotizing pneumonia will result in death within 24 or 48 hours of hospitalization and can be associated with disseminated intra- vascular coagulation and purpura fulminans. (Mongkolrathai et al, 2003) as well as meningo- coccemia. Bilateral adrenal haemorrhage and characteristics similar to WaterhouseFriderichsen Sundrome. (Adem et al, 2005). Before the spreading of CAMRSA some of the offensive syndromes were rarely associated with the S. aureus. However most of the researchers believe that these CA diseases became prevalent vary recently and the conditions like necrotizing fasciitis and Waterhouse Frederichsen syndrome tend to be the new ones. Clinical implications:Education plays a crucial role in disease management of an MRSA patient. This education should be done according to the degree of MRSA infection. For example, a patient with a severe MRSA should be educated how to decrease the transmission rates, eliminate the infection and prevent themselves from getting infected again. (Graffunder et al, 2002). Frequent hand washing, and

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removal of dirt with the help of an anti- microbial hand wash can prevent the spreading of infection to some extent, more usually in the house hold contacts. Infection control also includes the sexual contacts to prevent the partner from getting infected if the patient is sexually active. With respect to the location of infection, the draining pustules or sores must be properly covered with neat and tidy bandages. Special care should be taken to avoid contact with those draining boils and dirty bandages as well as the clothes. As most of the infections spread through the sharing of personal items, strictly avoid sharing the bath towels, bed sheets, razors, soaps, and clothing. Personal hygiene should be practiced and encourage regular hand washing and bathing. (Borlaug et al, 2005). When the treatment is initiated improvement should be seen within two days and the patients must be provided with specific information that explains the warning of systemic infections and the necessity for more aggressive treatment. There is a usual grooming practice of shaving, using removal creams or waxing the pubic hair which contributes to the infection in the people who has genital MRSA. They must be properly educated to prevent the chances of infection and also the problems of reoccurrence of the infection. (Kitajima et al, 2003). So there is a need for the healthcare professionals to enquire about various hair removal techniques which includes the type of razor used whether electrical or blade type, dry or wet shaving, usage or removal creams and lotions, blade replacement frequencies and so on. Thus accordingly for the people who remove this public hair with the help of laser techniques or waxing must be educated about the importance of reputed or licensed techniques. (Kitajima et al, 2003). There is a strong need for the discussion about various techniques used, hair removal frequencies, and the

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side effects in order to evaluate the risk factors in detail and also to educate the patients about them. There are more possibilities of genital transmission of CA- MRSA among the sexual partners, even though this infection is not considered as sexually transmitted disease and this contributes to another phase of educating the patients.(Graffunder et al, 2002). The individuals diagnosed with genital CA- MRSA need to be questioned about their partners whether they could find any pustules or boils in the groin or surrounding area of their sex partners. To avoid the possible chances of re infection, the proper examination of the sexual partners will be helpful. Whenever the evidences of CA- MRSA exist, a treatment method involving the decolonization of both individuals can be implemented. Most probably the people will be unaware of the hidden threat of the sexual transmission of CA- MRSA or wrongly believe that the condoms can protect against the possible infections. An open discussion of the sexual activities, which includes the number of sexual contacts and detailed screening for the infections, which are sexually transmitted, is very essential to provide the care for the patients who are diagnosed with CA- MRSA. The prevention of community associated MRSA is much important at the same time difficult in the presence of various risk factors and prevalence rates (Moran et al, 2006). There is a strong need for education about the basics of MRSA and a healthy life style among the female patients by the health care providers. This education must include proper hand washing, hygiene, sexual health and individual care. For the people who are living in the dense atmospheres, disinfection of the common places will be advisable. Periodical cleaning and washing of the clothes will help to improve personal hygiene (Borlaug et al, 2005).

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Investigation:When we consider the case of MRSA, the transmission of infection among the public seems to be the most threatening status at the present situation. As the MRSA lives on the skin, the most common way of spreading the infection is by the skin to skin contact. The other way is by sharing the personal items such as towels, bed sheets, razors etc. there are so many other possible ways that accounts for the spreading of CA- MRSA is by touching the public surfaces such as doorknobs, keypads, public toilets and tabletops which is always contaminated places. The CA- MRSA spreads through the prison inmates, children in daycare facilities, athletes, and homeless people or even among the family members. To support more on the ways of transmission of CA- MRSA, we can look into various instances that lead to the spreading of infection. Sports related MRSA transmissions:(Football)- Most probably various reports associated with the CA- MRSA infections on the athletes have focused mainly on football. Being a member of this sports team, the players are exposed to several factors that may lead them to infection. Various case reports pointed out the major risk of the skin infections resulted from injuries. (Rihm et al, 2005). Usage of artificial grass can aggravate the degree of skin injuries that is common among the players in the form of turf burns. At the same time athletes toe nails which are in-grown

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may also lead to the MRSA infections. (Kazakova et al, 2005). Investigations through different ways about MRSA outbreaks at various levels including school and college football teams, professional teams etc have shown some more risk factors. According to the study done by (Kazakova et al), during 2003 year football season showed 8 among the 58 players with the occurrence of MRSA infection but were not hospitalized. The causes of all of them were the turf burns and also the uncovered sites. Among another similar study to emboss the risk factors involved in MRSA, by reviewing 100 college players 13MRSA infections were indentified which included 10 team members. Hospitalizations were involved in the case of two players. 4 infections were reported in the shaved portions. In a study conducted in 2005 among the high school football team players, one case occurred with hospitalization. Among all these main risk factors were discovered to be wounds, turf burns, and abrasions. The author also founded out some of the MRSA cases in the dance team but by further investigation they could find out that the weight room played a role in spreading the infection which was before used by the football players and later by the dance team. (Borchardt et al, 2005). (Rugby)- Similar to football, rugby also involves much physical contact among the players even though there are other important risk factors for the occurrence of this disease. However the usage of the padded equipment in this game increases the possibility of skin to skin contact at the same time it also reduces the problems of sharing or untidy equipments. In one of the report from United Kingdom showed that 5 among the rugby team members developed the pustules in different areas including face, neck and arms. Under deep investigation it was found that only one of the players carried the

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organism intra-nasally and the outbreak happened through constant physical contacts but not through the equipments. (Stacey et al, 1998). (Wrestling)- Among the wrestlers frequent mat burns and chances of physical contact increases the possibility of getting infected with MRSA. (Lidenmayer et al, 1998). In a statewide survey conducted among the athletic trainers of a high school by the Texas department of health, revealed 6 infections. The other finding was the rate of infection was 0.3% which was little below the infection rate among the football players which is 0.4%. (Barr et al, 2006). In order to make clear about the doubts regarding MRSA some researchers have discussed about the complications among some special group of athletes. (Fencing)- MRSA has not only got the history of spreading through contact games. As per the CDCs reports in 2003, there was an outbreak of MRSA infections of about 5 cases among the fencers as well as the house hold contacts. Among them 3 were identified through culture and one involved house hold contact. Among the hospitalized patients, clinical presentation also varied from small pustules to dreadful bacteremia. (Eugine et al, 2008). (Volleyball)- The role of direct skin contact in the transmission of MRSA infections remains doubtful in the case of the volleyball players. As per the Texas department of health, 17 of the MRSA infection among 7053 high school volleyball players reported with MRSA infections. According to the survey which involved various types of sports teams, it was shown that the cases with cross country teams, and social contacts within the students thought to have helped in the contribution of MRSA infections. (Barr et al, 2006).

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(Weight lifting)- In one of the published reports, 3 of the weight lifters got infected with MRSA in the armpit also they all shared same recreational facility. From two of the male weight lifters they identified the bacteria which are resistant to fluroquinolones at the same time one of the patient experienced the re-occurrence of the skin infection. (Cohen et al, 2005). (Basket ball)- There are only 2 cases reported in the case of basket ball players. One of them in a Japanese player who got infected with multidrug resistant MRSA and it was not yet identified whether there are any risk factors involved in it. (Takizowa et al, 2005).the other infection was reported in a collegiate player with beta haemolytic Streptococcus. She was infected mainly in buttocks, labia majora as well as on thighs and she received a better treatment with the absence of reoccurances. (Cohen et al, 2005). CA MRSA transmissions among women:These infections is very common among the female population and more chances of spreading the infections through different ways including close contact with the sexual partners, minor rashes in the genital areas and also through vaginal colonizations. Most usually the clinical features of the infection vary in different individuals and there is a chance to get confused with other skin diseases. In a case of a 20 year old female, she was reported with a sore in her public area. She misunderstood her condition as herpes referring internet. But the laboratory results proved the fact that she was infected with MRSA skin infection by the microbiological culture. (Allyssa et al, 2010). Familial transmission of community associated MRSA:-

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CA- MRSA transmission between members of a family and among patients who are receiving the healthcare (Calfee et al, 2003) and also some of the case studies on the spreading of the infection between the family members will be looked into.(Faden et al, 2001). The study was conducted to identify the intra familial transmission of CA- MRSA in a time period of 2 years in Netherlands. Almost all the Dutch MRSA strains carry the pvl gene. (Wannet et al, 2003). The MRSA bacteria which are associated with the familial transmission were further characterized with the help of various techniques such as pulsed field gel electrophoresis (Mehrotra et al, 2003). SSC mec multiplex PCR (Ito et al, 2004), protein typing (Harmsen et al, 2003), Accessory gene regulator typing (Lina et al, 2000) and Multilocus sequence typing (Enright et al, 2000). Oligonucleotides were developed for the detection of exfoliative toxin D. the familial transmission of the disease can be explained as when two or more family members living in the same house are colonized with MRSA in PFGE typing. In the years 2003 and 2004, 10 cases of pvl associated MRSA transmissions were noted. Among them 7 were reported with infections on skin and 6 of the families had links with foreign countries. MRSA transmissions had happened from 2-4 members out of 6 members in a family. Studies had shown that all the MRSA affected individuals in the same family had same characteristics of typing under fine examination, which proves that transmission had taken place within the family members. Out of 10 families 7 had MRSA transmission occurred either from parent to child nor from child to parent. In one case it affected 2 siblings in 2 cases while 3 siblings in one case. These all cases show the prevalence of familial transmissions of MRSA skin infections. (Huijsdens et al, 2006).

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MRSA among the military associates:Similar to the studies in the prison, the researchers focused on outbreak investigations. The locations were military hospitals, ships, training facilities etc. the survey was also carried out for assessing the Staphylococcal carriage. Several other studies were also done on similar backgrounds. (Allison et al, 2006). Heterosexual transmission of community associated methicillin resistant Staphylococcus aureus:Apart from the usual means of transmissions of MRSA infections, there have been cases reported the heterosexuality as a means of transmission. In-order to explain the different ways of a new strain entering into a community, this possible way of transmission would be helpful. In a study was conducted on the individuals with MRSA positive cultures from Columbia University Medical Center catchment area. The time period was from April 2004 to September 2006. The patients suspected with MRSA positive were found out either with the help of a physician or clinical microbiology database. The study was conducted through interviews, demographic datas, medical records and the possible risk factors were also taken into consideration. They also collected samples from the armpits, nasal samples, vaginal and genital samples from all the adult members and tested for the presence of Staphylococcus aureus. The samples collected from the blisters were also cultured. Interviews were done in every 3 months up to the 9th month. Characterization by SSCmec typing and PFGE testing is done for all the bacterial cultures which marked positive. Three instances reported the heterosexual transmission of MRSA where both

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of the sex partners reported the frequent infection probably on the pubic or vaginal region. 1st case was a 3 year old girl with boils in her pubic area whose mother involved in sex with 5 different male partners including her husband had pimples in the groin area. 2nd case was the patient with buttock pustules which was MRSA positive and 2 months later her husband was reported with boils. Another instance is that they both were sexually active. 3rd patient was reported with MRSA positive abscesses several times over a period of 3 months. These pimples appeared soon after visiting her boyfriend who was a member of a military unit which was reported with an MRSA outbreak. From three of the cases, there were evidences of heterosexual transmission from clinical and microbiological tests. (Heather et al, 2006). Fomite transmission of CA- MRSA through the toilet seats:One area of possibility raised by the problems of shared use of things that helps in the fomite transmission. It was found out later on that the sharing of toilet by outpatients with the staff, patients and other people in some parts of the hospital. There occurred thought of the possible chance of fomite transmission through toilet seats. Through the study they could find out that MRSA can also be cultured in toilet seats in childrens hospital .In spite of regular and thorough cleaning. (Mary et al, 2009). MRSA transmission among incarcerated individuals:Four articles were studied was based on the outbreak of the CA- MRSA. The prevalence of MRSA from San Francisco county jail was found to have increased from 29%- 74% from 1997-2002. The risk factors of the transmission included the history of anti microbial use, inadequate hygiene,

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and co-morbidity. There are various studies done on the same topic and reached the unique conclusion of person person contact. (Allison et al, 2006). Results:There were different instances studied upon to find out various modes of possible transmissions and also the risk factors associated with the spreading of the infections. Sports related infections:(Football)- when we consider all the factors the author has reached a conclusion that various skin to skin contacts between the players, frequency of antibiotic usage, skin abrasions, close contact among the team members, the contaminated surroundings as well as the less personal hygiene among the team members and trainers may have played a major role in contributing to the outbreak of MRSA infections. The other possible way of infection is from the infected players in the opposing team and may have spread during the match. There was only one case identified by the researchers of the MRSA infection. Even after taking the preventive measures such as using the soaps containing chlorohexidine, proper caring of the cuts and wounds, antimicrobial therapy against MRSA infections, and the periodical examination of the possible infections on the skin. (Kazakova et al, 2005). In the case of the dancers developed infection, the authors found the fomites as the vector for the transmission of the MRSA infections. (borchardt et al, 2005). (Rugby)- To work against the MRSA outbreak among the rugby players, measures were taken not to participate and also not to use shared items. But it

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was found out that the infections has developed only among the people who participated, suggesting that the infection outbreaks most probably has resulted from the physical contact between the players or through the equipments used in the game.(Stacey et al, 1998). (Wrestling)- when we consider the wrestlers, from one of the case which shows two wrestlers infected but they never wrestled each other. It points out the possibility of occurrence through shared things rather than close contacts. (CDC, 2000-2003). The degree of contact between the individuals in these sports remains a controversy regarding the transmission modes. In another case as a part of preventing new infections, the teams implemented some of the preventive measures which included banning the MRSA affected wrestlers from the competition and also by encouraging personal hygiene with the use of antimicrobial soaps and cleaning of wrestling mats regularly. As a result they observed that there were no carriers or infections that had appeared in the next wrestling season pointing out the importance of preventive measures. (Lindenmayer et al, 1998). Another report among the wrestlers also showed the need for personal hygiene and proper care on the wound as well as cleaning the mats which is contaminated equipment after each and every use. (May et al, 1995). (Fencing)- According to a surveys findings, it was seen that the members of a fencing club shared the unsterilized fencing sensor wire which is worn under their clothes regularly. Along with this they also experienced irritation on their skin due to the use of the protective clothing. This proves that the transmissions may be acquired through the fomite. (Borchardt et al, 2005).

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(Cross country)- Cross country is a non- contact sport, and there were some solitary incidence of the outbreaks of MRSA among the team members. This always supports the conclusion that the cause of infection might be from the shred personal items or equipments. The numbers of reported cases also supports this idea. (Barr et al, 2006). (Weight lifting)- Only one of the published reports is linked with the MRSA infections among the weight lifters. On clear examination it was found out that all the affected individuals used the same gym equipments and that may have contributed in the transmission of the infections. The sensitivity directed antibiotic therapy and cleansing the affected area with the antibacterial agents such as chlorohexidine or povidone- iodine was found to be effective. (Cohen et al, 2005). (Basketball)- In the literature there exist only 2 cases of MRSA infections among the basket ball players. One case showed the infection to the anterolateral aspect of the thigh. The condition was improved with the initial visit without re-occurrence of the MRSA infection. (Cohen et al, 2005). Another report was the occurrence of multidrug resistant MRSA but failed to find out any of the risk factors linked with. (Takizawa et al, 2005). (Soccer)- There are also reports of MRSA infection among the soccer players. As a part of the prevention of infection and their further transmission, the team officials encouraged preventive/control measures of washing hands, strict cleaning facilities, using towel while sitting on a bench, etc. it was concluded that the infection may have transmitted by sharing the same equipments and also through skin to skin contact. (Huijsdens et al, 2006).

25

CA- MRSA in women:Reports are suggesting that MRSA colonization is frequently found among the pregnant women. It is also responsible for various complications and serious infections. (Cheng et al, 2006). Sin the past decade MRSA related mastitis has increased drastically and the causative agent was identified as maternal CAMRSA infection. (Jarvis et al, 2006). In addition to these infections, neonatal infections and colonizations of CA- MRSA are becoming common in the hospital new born nurseries. (Stafford et al, 2008). The elimination of these infections tends to be a difficult process as the microorganisms can survive on the hospital equipments for a longer periods. (Nguyen et al, 2007). Transmission of the infection among the post partum women can also be linked with the maternity and new born nursery infections. (Bratu et al, 2005). Other factors that may lead to the infection in the new born nurseries are unhygienic atmospheres, lack of proper hand-washing, fail to take precautions against the infection outbreak, the absence of infants rooming with the mothers etc. (Hota et al, 2004). When the practice of pubic hair removal became common (Kitajima et al, 2003) the surrounding regions and organs became more susceptible to the bacterial infections. (CA- MRSA). Various techniques of hair removal including mechanical ways such as shaving, as well as waxing create minor rashes on the skin. That may lead to MRSA infection and can even help in the spreading of dreadful pathogens, (i.e. HPV- Human Papilloma Virus, HSV- Herpes Simplex Virus etc). (Braue et al, 2005). According to a study conducted by Thurman et al, to rate the abscesses in vulva among the

26

women none of the patients were hospitalized within one month of their visit. MRSA of about 64% was isolated from the vulvar cultures. The findings of these reports are reliable with the previous results occurrence of MRSA infections. (Thurman et al, 2008). Sexual transmission and MRSA colonization has been reported also among the men who are having sexual relationship with men. (Klevens et al, 2007). In addition to these, clinicians have reported that the colonization with CA- MRSA in the genital area among the heterosexual individuals can mainly result in the spreading of the infection through the sexual practices. It will also contribute to frequent genital infection even among the healthy people. (Graffunder et al, 2002). According to various authors, close contact among the sexual partners is directly related with the chances of skin infection and thereby with the CA- MRSA among the couples. These also contribute in the spreading of infection within the community. (Graffunder et al, 2002). Transmission through household contacts:The frequency of transmission and the risk factors of MRSA affected individuals to the household contacts were investigated in a study conducted between 2005 January and 2007 December. Altogether 62 affected individuals and their 160 household connections were included in the study. The results revealed that MRSA transmission among the household contacts had occurred around 47%. All these affected individuals had 84 household connections among which 2/3 became MRSA positive. The significant risk factor for the transmission of MRSA among the household contacts in this particular study was found to be prolonged exposure time to MRSA at home. Regardless to

27

these, there were also other significant factors such as younger age, MRSA colonization in the nares and throat, eczema in the reference individuals etc had contributed for the transmissions. But the presence of wounds was found to be negatively associated with the transmission of infection.

FIG. 1. Rates of MRSA colonization of sites in 62 MRSA-positive index persons. n, nose only; t, throat only; p, perineum only; o, other only; nt, nose + throat; np, nose + perineum; no, nose + other; tp, throat + perineum; po, perineum + other; ntp, nose + throat + perineum; nto,nose + throat other; tpo, throat+ perineum + other; npo, nose + perineum + other; ntpo, nose + throat + perineum + other.

In addition, the household contacts and being the partner of the reference individual were the risk factors which were found as household related ones. With regard to the MRSA transmission among the healthcare settings and

28

community, carriage of infectious pathogens play an important role. (Boyce et al, 1989). There was a search and destroy infection policy and also strict antibiotic policy which was formulated in Netherlands. As an impact, there showed very limited number of MRSA colonized individuals. (European Antimicrobial Resistance Surveillance System, 2007). In this policy the destroy part was found to be very important at the same time effective, as it has eliminated 2/3 of the found reservoirs. They were carriage of pathogens in patients, carriage of MRSA in health care workers and the one that they couldnt eliminate is the environment. Even in the low prevalence countries, the emergence of CA- MRSA had caused a notable change in the epidemiology of MRSA and a rise in the number of MRSA cases. (European Antimicrobial Resistance Surveillance System, 2007).

Familial transmissions of MRSA:A study was done in Netherlands by Huijsdens et al, on multiple cases of familial transmission of MRSA infections. According to the results obtained through the work, there were positive signs of transmissions occurred either from the parent to the child or from the child to the parent. At the same time it has also affected the siblings and they could discover that the family members were colonized with MRSA bacteria drawing the fact that family members can act as one of the best reservoirs of CA- MRSA. Therefore it spreads among all the family members and household contacts. (Huijsdens et al, 2006).

29

Transmission of MRSA among incarcerated individuals:-

Allison et al, mentioned about 7 articles with MRSA among incarcerated individuals. Five of the states the jailed populations. Three among the incarcerated people. It was found that the prevalence of MRSA infections among the samples collected from the San Francisco Country Jailed System increased from 29%- 74%. It was reported from the year 1997- 2002. Other discovery was the presence of SSCmec IV which is commonly found in association with CA- MRSA. (Pan et al, 2003). Various risk factors were implicated in the MRSA outbreaks among the jail inmates in imprisonment facilities. Those characteristics are co- morbidities, inadequate hygiene, antimicrobial usage, factors related with crowding etc. Majority of the MRSA isolates were susceptible to all the antimicrobials except lactam antimicrobial and erythromycin. As the clones identified from the isolates were indistinguishable, it was proposed that the transmission had occurred person to person.

Characteristics

CA- MRSA

Associated with frequent or long term antibiotic

No

30

use and medical co- morbidities

Associated with health care exposure in the past year.

Yes

Usually causes skin and soft tissue infections and pneumonia

Yes

Resistant to lactam antibiotics

Yes

Resistant to clindamycin and fluroquinolones SCCmec Type I-III Type IV-V

Yes/No No Yes

Panton valentine Leukocidin

Yes

Table :- Characteristics of CA- MRSA (Fridkin et al, 2005).

31

Transmission of MRSA among the prisoners:According to one of the investigation, 22 military recruits were identified with mecA positive isolates, carrying the pvl gene and also multilocus type 8 sequence. (Campbell et al, 2002). This study suggested that in the military settings, sharing the crowded barracks may have contributed to the transmission. The studies also postulated that lack of hygeine, & cuts and wounds associated with training may have influenced in the outbreak of MRSA infection among the trainee members however these studies are not associated with the statistical tests. (Zinderman et al, 2004). The findings also included the susceptibility to all the antimicrobial agents except erythromycin and lactam antimicrobials. All the five studies used strain typing technique in which four of them reported to have the similar type of strains.

The chart below shows various studies involved with the CA- MRSA infections among the prisoners, number of individuals involved and the reported risk factors:-

32

33

Transmission of CA- MRSA from father to infant:A study by Jaffer.A, focusses on a case report of a new born female with MRSA positive in respiratory specimen at the same time without the signs and symptoms of pneumonia. The infants parents didnt have any specific medical history and were healthy. The screening of the specimens of nasal swabs obtained positive results for the neonate and the father while it resulted negetive for the mother. Among the MRSa obtained, two strains from the father and the infant showed similar properties of susceptibilty towards ciprofloxacin, clindamycin, vancomycin and erythromycin at the same time they had similar antibiogram as well. Transmission among the family members and from mother to the child has been reported by (Hollis et al, 1995). The

34

isolates from the mother and infant was indicating identical in the DNA analysis and antibiograms. CA- MRSA has also been described in the children with and without recognisable risk factors. (Herold et al, 1998).

CA- MRSA transmission through hetero sexual partners:According to some of the case reports, there were instances of heterosexual transmission of CA- MRSA infection in which they studied it thoroughly with the help of microbiological assesments, clinical testing and molecular

epidemiological datas of the heterosexual transmission of MRSA. After the sexual activity the partners got bactrial colonization and further skin infections in the pelvic region. Infections was found to be cused by the same strains in different individuals. Most of the women had asymptomatic pubic and vaginal colonization with the MRSA bacteria. But 75% of the nare cultures didnt report any of the bacterial growth. Heterosexual activity increases the chances of risk factors for the trnsmission of CA- MRSA through close contacts, skin to skin interaction, presence of wounds, or skin abrasions which has been resulted from shaving or viral infection, cuts which are not properly covered etc. (Naimi et al, 2003). Other risk main factor is the sexual activity with the affceted individuals. (Lee et al, 2005). Heterosexual activity is causing a great threat to the society by spreading the infection and in that case it can act like sexually transmitted disease. It has been reported that the nasal colonization rates of CA- MRSA has become low among the public. (Kuehnert et al, 2006). Eventhough when some group of people such as military recruits, children and homess people shows higher possibility of nasal colonization, other group of

35

people including athletes, the colonization chnaces remain very low. (Creech et al, 2006). In the study, the cultures data from the clinical microbiology database gives the suggestion that bacterial colonization in different sites are comparitively common. The assesments revealed the fact that the alternative colonization sites plays the similar role of primary sites in causing the infection and transmission of diseases. Previously the heterosexual activity was not being reported as the possible and important means of transmission of CA- MRSA. The study by (Heather et al, 2007) suggests that the bacterial colonization of genital area, pubic area and the hetrosexual activity among the adult individuals of the family can result in the spread of the MRSA infection among the other individuals. Male gender as a significany risk factor:In a study which had focussed on finding out the gender as a risk factor, cases were reported during a 7 year time- period among the people aged between 50 and 74. It showed predominance of male gender. 62.6% people were admitted directly from their homes. MRSA prevalence was noted highest in ICU (Intensive care unit) and the male gender was significantly correlated with the amplified risk of MRSA acquisition (P<0.001). it was found that 75% of the MRSA positive patients were 50 years of age. (Kupfer et al, 2010).

36

Discussion:As far as we have come across various forms of transmissions of CA- MRSA, we could find out the wide range of possibilities of getting infected. Among them the most important way is the sports related CA- MRSA transmission in which different sports items having their own ways of transmission and range of infectivity. When we consider the case of football, it was found to be top among the MRSA reported sport as it is a contact team sport. The higher risk site was found out as the areas with compromised skin due to athletic injury. (Rihn et al, 2005). Artificial turf can also increase the extent of injury that is common among the football players as turf burns which may lead to MRSA infection. (Kazakova et al, 2005). But some of the other authors have pointed out the shared facilities as the culprit for the spread of infections. As like the community facilities playing a role in transmissions, the sharing of personal items can also contribute in the spreading. According to the health departments it was identified that the sharing of lubricants, untidy bath towels, clothes, balms etc as the predictable modes of transmission. (CDC et al, 2003). Some studies have come across the therapies on the players and reported a failure to respond for the lactam antimicrobials. Apart from these the players who had undergone the empiric treatment exhibited 33 times riskier for re- infection than the ones who had undergone the culture guided treatment. (Rihn et al, 2005). In rugby, the limited use of padded material creates chances for more skin to skin contact bat the same time helps in bringing down the risk associated with contaminated and shared equipments. From the observation of the players the researchers could doubt that the outbreak might have resulted from the physical contact more than the sharing of the equipments. (Stacey et

37

al, 1998). In the case of wrestling, MRSA infections occur as a result of prolonged physical contact with other players and constant mat burns. (Lindenmayer et al, 1998). In comparison rate of football players was found 0.4% which was slightly higher than the infection rate among the wrestlers which was 0.3%. (Barr et al, 2006). Another report has estimated that the transmission of the infection might have occurred from sharing the items rather than close contacts. (CDC et al, 2003). Even though the extent of person to person contact in this sports item remain as an important and possible mode of transmission. Another group of investigators did some control measures to find out the mode of transmission and it suggested that preventive measures had a positive impact. (Lindenmayer et al, 1998). Evidences dont support the link between the patient infection and the contaminated wrestling areas, but the authors has given more importance for regular cleaning of equipments as well as surfaces and personal hygiene. (May et al, 1995). Some of the surveys had found out the main cause of the infections among the fencing team members is the sharing of unsterilized sensor wires and came to a conclusion that they might have transmitted through fomites. (CDC, 2003). The role played by direct skin to skin contacts remains controversial in the transmission of MRSA among the cross country and volleyball team members. In weight lifting the usage of sensitivity directed antibiotic therapy, antibacterial agent therapy, topical mupirocin etc were found to be effective. (Cohen et al, 2005). Among the soccer players to prevent transmission, the team members were encouraged to practice healthy habits and the researchers suspected that the transmission might have occurred through the shared equipments. (Huijsdens et al, 2006). So from the whole sports related infections it appears that the

38

primary mode of transmission of the MRSA infections is the person to person dose contacts, and the prevalence differs in various sports. Thus athletes may better go for the broad preventive measures. (Table). Table 1:- Centres for Disease Control Prevention- Measures for preventing staphylococcal skin infections among sports participants.

1) Cover all wounds. If a wound cannot be covered adequately, consider excluding players with potentially infectious skin leisons from practice or competitions until. 2) Encourage good hygeine, including showering and washing with soap after all practices and competitions. 3) Ensure availability of adequate soap and hot water. 4) Discourage sharing of towels and personal items. (eg:- clothing or equipment). 5) Establish routine cleaning schedules for shared equipment). 6) Train athletes and coaches in first aid for wounds and recognition of wounds that are potentially infected. 7) Encourage athletes to report skin leisons to coaches to assess athletes regularly for skin leisons. Reprinted with permission from the Centers for Disease Control and Prevention. (CDC, 2003) Following the CDC guidelines, some authors have concluded that the risk of cutaneous MRSA infections got reduced. (Romano et al, 2006). Apart from the table, the hygienic practices such as using higher temperature water for the laundry purposes, hand- sanitizers with alcohol; disposable paper towels etc

39

should be encouraged. The National Collegiate Athletic Association (NCAA) gives a suggestion of keeping shorter nails of less than 0.25 inch length and removing jewellery in order to avoid scratches. (National Collegiate Athletic Association, 2007). In the case of fomite transmission the extent of contamination serves as a major factor and the teams should use the sterilized wrestling mats and equipments. (Elston et al, 2007). Even though MRSA exhibits minor level of resistance against triclosan, chlorohexidine and various quaternary ammonium compounds, they are found to be effective in killing MRSA. (Suller et al, 1999). Alcohol alone can display bactericidal activity and when combined with chlorohexidine preparation it exhibits the bactericidal effects. (Elston et al, 2007). The quaternary ammonium compounds (i.e low level disinfectants) have the ability to inactivate most of the bacteria as well as some viruses and fungi. Although the recommendation given by these associations provides guidance in one way they lack evidences in the other way. (Kirkland et al, 2008). In the case of the nasal carriages, most of the reports either found to be very few or to be MRSA negative cultures. The MRSA positive nasal carriages occur as transiently but long term carriages also exists rarely. (Kluytmans et al, 2005). Some of the researchers still agree against the surveillance culture due to lack of evidences supporting it. (Lu et al, 2005). There was a controversy regarding the possibility of leading to drug resistance and prevention of disease. (Lu et al, 2005). More studies are required regarding the proper effect of nasal de-colonization. (Kluytmans et al, 1997). Even though the extent of prevention from MRSA by soaps has not been studied, it can control the infections. (Romano et al, 2006). In the study based on the prevention of transmission in the neonatal unit, to prevent the

40

MRSA transmission without an outbreak, they placed an extended infection prevention measures which included stepwise treatments and also by considering each and every case. (Rajan et al, 2007). The disadvantage related with PCR based MRSA detection and screening is that it involves high cost. (Conterno et al, 2007). There is a strong need of cost- effective PCR based MRSA surveillance for the control and prevention of this disease. The report based on the outbreak of HA and the transmitted CA- MRSA strain was the first published one and epidemiologic investigations failed to find out the route of transmission of the disease during the outbreak. They couldnt find out the MRSA in health care workers in the surroundings. This strain identified didnt have resistance to antimicrobials other than lactam agents and was reported with blaZ gene encoding penicillinase and SCCmecIV encoding penicillin binding protein 2. (Baba et al, 2002). The investigation had limitation without explaining the route of transmission. With regard to the CA- MRSA infections among women, it was found out that they are very common and frequent in the females with the presence of vaginal colonization, sexual contact and minor abrasions on the skin. It was advised that the patient education, risk reduction and awareness can only control the degree of transmissions. (Allyssa et al, 2010). When the studies have done regarding the transmissions among the household contacts, it was showing 47% of occurrences. From an index person to the households. The number of person with the infection also plays an important role in transmission. There were several risk factors that were found in the study and they are throat carriage of the MRSA of index individual, respiratory secretion, coughing, sneezing, kissing, exposure time at home and also the relationship of the household

41

contact with the index person. (Mollema et al, 2009). As per the report on the familial transmissions, the family members can act as reservoirs for the spread of the disease and the prevalence rates tends to be higher than what is reported as they are not routinely tested. (Huijsdens et al, 2006). There the clinical, micro biological and epidemiological evidence regarding the heterosexual activity has been linked with the close contacts, open wounds, and micro abrasions etc. (Salgado et al, 2003). Within the U.S prison and the military personal, there showed the prevalence of multidrug resistant organism i.e. MRSA. The U.S holds second highest rate of incarceration in the whole world. Since 1980, the incarceration rate has increased by more than 3005. (Bureau of Justice, 2006). In a population based study conducted by the U.S National Health and Nutrition Examination

Survey during 2001- 2002, the two main risk factors they could identify is young age and the non- Hispanic black ethnicity. (Kuehnert et al, 2006). The factors that might help in increasing the risk were found to be living in crowded atmospheres, various skin diseases, and also immune- suppression. (Said- Salim et al, 2003). Before incarceration and after released from the prison, the prisoners can act as a major reservoir of resistant organisms that are likely to be transmitted to the population.

42

Conclusion:Most of the studies, surveys and evidences linking with CA- MRSA transmissions are the sports related MRSA transmissions. There were different transmission modes which have been discussed in this paper. They can be explained as skin to skin contact, close contacts, house hold contacts, from the contaminated clothes, bath towels, equipments, sports related equipments, turfs, mats, nasal colonization, contaminated surroundings, activities such sexual practices, coughing, sneezing, kissing, uncovered wounds etc. majority of the authors have reported regarding skin to skin transmissions, and the ones through close contacts. The effective way to reduce the transmissions was found to be the prevention of infection. For that various researches had dealt about the importance of preventive or control measures which showed the real success in some case studies. For the spread of infections in jails, prisons and military settings person to person contact was the main reason and had a high prevalence of MRSA among the individuals that receive clinical treatment. The guidelines which were provided in all the cases almost included precautions, diagnosis, treatments, and protocols to control the infections. The other recommendations were the maintenance and enforcement of proper hygiene all through the day, cleanliness of the bath rooms, and awareness among individuals. The CA- MRSA among the women appeared frequently and also transmitted because of vaginal colonization and sexual activity. So, it was recommended for the increased awareness among the health care providers, for risk reduction as well as patient education. In the familial transmission of MRSA it was suggested to investigate the nosocominal outbreak of the bacterial colonization, at the same time the health histories of

43

the parents was supposed to be considered. There is a need for the implementation of active surveillance cultures and the contact precaution in order to avoid the spreading of infections. As a whole patient education plays a crucial role in the infection reduction and management of CA- MRSA.

44

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