MRSA

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MRSA means methicillin-resistant Staphylococcus aureus bacteria. The majority of MRSA infections are classified as CA-MRSA (community acquired) or HA-MRSA (hospital- or health-care-acquired).

The majority of CA-MRSA starts as skin infections; HA-MRSA can begin an infection of the skin, a wound (often a surgical site), or a location where medical devices are placed (catheters, IV lines, or other devices). MRSA was first noted in 1961, about two years after the antibiotic methicillin was initially used to treat S. aureusand other infectious bacteria. The resistance to methicillin was due to a penicillinbinding protein coded for by a mobile genetic element termed the methicillin-resistant gene (mecA). In recent years, the gene has continued to evolve so that many MRSA strains are currently resistant to several different antibiotics such as penicillin, oxacillin, and amoxicillin (Amoxil, Dispermox, Trimox). HA-MRSA are often also resistant totetracycline (Sumycin), erythromycin (E-Mycin, Eryc, Ery-Tab, PCE, Pediazole, Ilosone), and clindamycin (Cleocin). In 2009, research showed that many antibiotic-resistant genes and toxins are bundled and transferred together to other bacteria, which speed the development of toxic and resistant strains of MRSA. S. aureus is sometimes termed a "superbug" because of its ability to be resistant to several antibiotics. MRSA is short for methicillin-resistantStaphylococcus aureus. It is a strain of bacteria resistant to certain types of antibiotics. It is a less common, but potentially more serious, form of the common "staph" infection.
Until recently, MRSA was more likely to be a hospital-acquired infection. MRSA infections that are first acquired in the hospitals and healthcare facilities are known as healthcareassociated MRSA. New strains, however, have recently emerged in the community that are capable of causing severe infections in otherwise healthy individuals. These MRSA infections are known as community-associated MRSA.

This organism was first identified in 1880 by a surgeon, Alexander Ogston, who noted that the majority of abscesses he studied which were inflamed and warm to touch were caused by the same organism. In 1928, penicillin was discovered and was found effective in treating S. aureus. In 1959, the first semi-synthetic penicillin, methicillin, was produces by altering the chemical composition of penicillin. Two years later, the first methicillin resistant strains of S. aureus were reported. S. aureus that is resistant to the synthetic penicillins (methicillin, oxacillin, nafcillin) is referred to as methicillin-resistant S. aureus (MRSA). It is also resistant to cephalosporins and sometimes to other antibiotics (erythromycin, clindamycin, aminoglycosides, quinolone).

The first documented nosocomial outbreak of MRSA in the United States occurred at Boston City Hospital in 1968. The investigation of this outbreak supported transmission by the direct contact of hands of personnel to patients in the ward. Since this outbreak, numerous units, intensive care unites, hospital ward, and in the community at large.

Colonization:
It is important for the health care professional to understand the difference between colonization and infection. Colonization indicates the presence of the organism without symptoms of illness. Colonization can occur in the nares, trachea, skin folds, rectum, or in an open wound such as decubitus ulcer. The patient does not symptoms when colonized. 70 % to 90% of all individuals are intermittently colonized with S. aureus (methicillin susceptible or resistant) in the anterior nares. S. aureus permanently colonized the anterior nares of about 20% to 30% of the general population. Hospital workers are more likely to be colonized than persons in the general population, presumably because of increased exposure. Thus, a higher colonization rate with S. aureus is responsibility of the physician to determine if a patient is colonized or infected. Colonization with MRSA is not an indication for hospital admission or for prolonged hospitalization provided appropriate arrangements for disposition can be made (e.g. discharge to home or extended care facility).

Infection:
Infection is defined as tissue invasion by S. aureus with subsequent clinical symptoms. Clinical manifestations of infections caused by S. aureus can range from superficial skin lesions such as boils to deeper infections such as pneumonia which can progress to death. In addition to local symptoms and signs of infection, systemic manifestation of disease such as fever, malaise, and leukocytosis are often present.

Treatment of Infections:
Treatment for an infection due to MRSA may be indication for hospital admission. The standard antibiotic therapy for infections caused by MRSA is intravenous Vancomycin. Vancomycin can have serious side effects, especially in elderly persons. These side effects could include ototoxicity (loss of hearing or other auditory damage), nephrotoxicity (damage to the kidneys or renal system), and allergic reactions such as fever and rash. Infusion of vancomycin, especially when to rapid, can result in flushing, hypotension, and tachycardia known as the red man syndrome. Vancomycin given by mouth is not absorbed and is not effective against MRSA.

Decolonization:

Decolonization is the elimination of MRSA carrier state through the use of infection control measures and/or antibiotics. The indications for and efficacy of decolonization vary depending on the unique circumstances surrounding a particular episode or outbreak of MRSA colonization/infection. The effectiveness of permanent decolonization seems marginal, but special circumstances may warrant an attempt. Examples of special circumstances include the following: 1) patients who are immunosuppressed and colonized, and therefore, might develop particularly serious infections, 2) patients who are more likely to spread the organisms, due to behavior (e.g. the mentally retarded), or 30 patients who have repeated infections caused by the MRSA strain that they carry. Decolonization protocols may include the use of oral/topical antibiotics. A physician should assess each situation (an infectious disease specialist may be consulted for decolonization protocol).

Community-Associated MRSA Risk Factors

Many people who live in the community and develop MRSA infections do not have any risk factors. However, there appear to be several factors that can increase a person's chances for developing community-associated MRSA. Some of these risk factors include:

y Trauma to the skin (such as cuts, sores, or "turf burns") y Participating in contact sports (particularly wrestlers, gymnasts, and those who play lineman or linebacker in football) y Being overweight or obese (see BMI Calculator for your ideal weight) y Shaving body hair y Physical contact with a person who has a draining cut or sore, or who is a carrier of MRSA y Sharing towels, uniforms, razors, or other personal items or equipment that is not washed between users y Living in crowded or unsanitary places, such as prisons, military barracks, or homeless shelters.

Most MRSA infections are skin infections that produce the following signs y

and symptoms:

cellulitis (infection of the skin or the fat and tissues that lie immediately beneath the skin, usually starting as small red bumps in the skin),

boils (pus-filled infections of hair follicles),

abscesses (collections of pus in under the skin),

sty (infection of eyelid gland),

carbuncles (infections larger than an abscess, usually with several openings to the skin),

and

impetigo (a skin infection with pus-filled blisters).

One major problem with MRSA is that occasionally the skin infection can spread to almost any other organ in the body. When this happens, more severe symptoms develop.

MRSA transmission
Ways you could get MRSA Touching infected skin of someone who has MRSA. Using personal items of someone who has MRSA, such as towels, razors, clothes, or athletic equipment. Touching objects, such as phones or door knobs, that have MRSA bacteria on the surface and then touching your nose or open sore, paper cut, etc. Ways to increase your chances of getting MRSA Using lots of antibiotics. Taking antibiotics without a doctor s order. Not following your doctor s directions when taking antibiotics (for example, skipping doses or stopping your antibiotics before finishing a prescription). Cuts or scrapes on your skin (skin is a barrier to infection). Poor hygiene.

Active infection vs. Carrier of MRSA

1. Active infection. You have symptoms. Usually a boil, sore or cut that is red, swollen or pus-filled. 2. Carrier. No symptoms, but still has MRSA living in the nose or skin. Your doctor may say that you are colonized or a carrier .

When you go to a clinic or hospital

If you have ever had a MRSA infection or if you are a carrier, you should tell your health care providers. They will wash their hands and wear gloves when caring for you. They may

also wear a gown over their clothes and may wear a mask. Visitors may be instructed to avoid touching infected skin and to take other precautions such as wearing gloves or gowns.

MRSA diagnosis
You may not be tested for MRSA unless you have an active infection. If you have a skin infection, the doctor may take a sample (culture) to find the cause of the infection. The lab will test the bacteria to find the best antibiotic. If your MRSA infections keep returning, your doctor may test you and your family members to see if you are carriers.

What does a MRSA infection look like?

On the skin, MRSA infection may begin as a reddish rash with lesion(s) that looks like a pimple or small boil. Often it progresses to an open, inflamed area of skin (as pictured below) that may weep pus or drain other similar fluid. In some instances, it may appear as an abscess, a swollen, tender area, often with reddish skin covering. When the abscess is cut open or spontaneously bursts open, pus drains from the area

Treating MRSA
Treatment for MRSA MRSA should always be treated by a doctor. You must follow the doctor s directions. Many people with active infections are treated effectively and no longer have MRSA. Sometimes MRSA goes away after treatment and comes back again.

If you have an active MRSA infection, your doctor may use one or more of the following treatments: 1. Antibiotics. MRSA is resistant to many antibiotics so treatment can be difficult. However, some special antibiotics can treat MRSA. If your doctor gives you antibiotics, take them exactly as ordered. Do not stop early, even if you feel better or if the infection looks healed. The last few pills kill the toughest bacteria. Never take antibiotics without a doctor s order. 2. Drain the infection. Don t do this yourself. It is dangerous to squeeze or poke a skin infection because it can drive the bacteria deeper into the skin and make the infection worse. Your doctor will open and drain the sore. Then keep the sore covered with a clean, dry bandage, until it heals. 3. Reduce the staph on your skin or in your nose. This may prevent the spread of MRSA. To decrease the staph on your body your doctor may, for a short period of time: Tell you to shower daily with antibacterial soap. Prescribe antibiotic ointment to put in your nose. In some cases, prescribe antibiotic pills.
Treatment of HA-MRSA frequently involves the use of vancomycin, often in combination with other antibiotics given by IV; CA-MRSA can often be treated on an outpatient basis with specific oral or topical antibiotics, but some serious CA-MRSA infections (for example, pneumonia) often require appropriate antibiotics by IV.

Preventing the spread of MRSA

Wash your hands often with soap and water or alcohol-based

hand sanitizer. Bathe or shower often, using soap. Wash your sheets and towels at least once a week. Change clothes daily and wash them before wearing again. Do not share towels, razors, or other personal items. Keep cuts and scrapes clean, and covered with a bandage. Do not touch sores; if you do, wash your hands immediately. Cover infected sores with a bandage. Wash your hands right away after putting on the bandage. Wear clothes to cover bandages and sores, if possible. Clean frequently used areas of your home (bathrooms, countertops, etc.) every day with a household cleaner. Unless directed by a physician, students with MRSA infections should not be excluded from attending school. Children should be excluded from school if they have draining wounds that can t be covered and contained with a dry bandage and if they can t maintain good personal hygiene. Students with active infections should be excluded from activities where skin-to-skin contact is likely to occur (e.g., sports) until their infections are healed. Do not use a public gym, sauna, hot tub or pool until sores have healed. Wash your hands often Wash your hands with water and soap for 20 seconds.

Or clean hands with alcohol-based hand sanitizer

What is the prognosis (outlook), and what are the potential complications for people with MRSA infections?
Statistics from the Kaiser foundation in 2007 (http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=45809) indicated that about 1.2 million hospitalized patients have MRSA, and the mortality (death) rate was estimated to be between 4%-10%. These data have not been updated by the CDC yet. Another study suggested that the mortality rate may be as high as 23%. In general, the average adult death rate was about 5% of infected patients in 2010. Fortunately, in children under 18 years of age, a recent (2009) study suggests their mortality rate is much lower (about 1%), even though the number of hospitalized children with MRSA has almost tripled since 2002. In general, CA-MRSA has far less risk of any complications than HA-MRSA as long as the patient does well with treatment and does not require hospitalization. However, people who do suffer complications generally have a chance for a worse outcome, as organ systems may be irreversibly damaged. Complications from MRSA can occur in almost all organ systems; the following is a listing of some that can result in permanent organ damage or death: endocarditis, kidney or lung infections (pneumonia), necrotizing fasciitis, osteomyelitis, and sepsis. Early diagnosis and treatment usually result in better outcomes and reduction or elimination of further complications.

Who Is at Risk for Getting MRSA?

MRSA is a type of bacterial infection that can affect anyone. However, some people may have a higher risk of getting this type of infection. For example, people who are in hospitals or healthcare facilities may acquire healthcare-associated MRSA. There is also a community-associated MRSA. Risk factors for getting MRSA include things such as being overweight, living in unsanitary places, or participating in contact sports (such as wrestling).

ADMISSION/DISCHARGE
The issue of MRSA status (negative culture, colonized, or infected) with regard to hospital and non-acute care facility admission and discharge warrants attention. This issue is of great practical significance in light of the current misinformation, fear and the natural inadequacies of complete, preventive control measures for infection and colonization. An institution should not deny admission to a person colonized or infected with MRSA if adequate facilities are available to deal with MRSA. HOSPITAL ADMISSION

Admission Rationale: Hospital admission because of MRSA infection is acceptable medical practice. However, MRSA colonization does not, by itself, warrant hospital admission. Treatment for infection with MRSA is usually accomplished in an acutecare setting. However, treatment for infection can be accomplished in a non-acute care facility or at home. Such decisions should be based on the clinical judgement of the attending physician. Room Assignment: A private room is preferred for MRSA infected of colonized patients. The MRSA colonized patient can be placed with another colonized patient (cohort). If cohorting is not possible, the MRSA colonized patient can be placed with a non-colonized patient. The MRSA-colonized patient should not be placed in a room with a patient who is a high risk for infection (i.e. a patient with a tracheostomy, gastrostomy tube, central line, urinary catheter, open wound, or immunocompromised). A colonized patient with poor hygiene may need to be in a private room. Infection Control: Standard infection control guidelines (See Appendix II) should be followed. The facility may employ a stricter infection control policy if so directed by the Infection Control Committee. HOSPITAL DISCHARGE Upon completion of appropriate therapy for MRSA infection, and when the clinical manifestation have resolved (even if the patient has a positive culture) hospital discharge may be indicated. A patient colonized with MRSA while hospitalized for another illness may be discharged once that illness is under control. In other words, a patient may be discharged from an acute-care setting with a positive MRSA culture. When this occurs, the hospital should notify, in advance any institution/agency receiving the patent that he/she is colonized with MRSA. A negative culture should not be a prerequisite for transfer to another facility.

NON-ACUTE CARE FACILITY ADMISSION Admission Rationale: An institution should not deny admission to a person colonized or infected with MRSA if adequate facilities are available to deal with MRSA. A person colonized with MRSA should be allowed admission to a non-acute care facility. Under special circumstances, treatment for an MRSA infection can be accomplished in the no-acute care facility. This decision is based on clinical judgment of attending physician and capabilities of the institution, and should be negotiated between the discharging and receiving physicians/facilities. Room Assignment: A private room is preferred for MRSA infected or colonized patients. The MRSA colonized patient can be placed with another colonized patient (cohort). If cohorting is not possible, the MRSA colonized patient can be placed with a non-colonized patient. The MRSA colonized person should not be placed in a room with a person at high risk for infection (i.e., a resident with a tracheostomy, a gastrostomy, central line, urinary catheter, open wound or immunocompromised). A colonized person with poor hygiene may need to be in a private room. Infection Control: Standard infection control guidelines (see Appendix II) should be followed. The facility may employ a stricter infection control policy if so directed by the Infection Control Committee. NON-ACUTE CARE FACITLITY A patient may be discharged to home or hospital while colonized with MRSA. When a MRSA-colonized/infected patients is transferred to and acute care setting, the receiving institution/agency should be notified, in advance, of the patients MRSA status. DISCHARGE TO HOME: If the patient is discharged from an acute or non-acute care facility to a private hone, the family should be educated that there is a difference in risk between MRSA infection in the setting of a health care facility versus the home setting. The patients family will usually have noted the discharging institutions additional attention to infection control practices and my have questions regarding 1) the need to duplicate these infection control practices in the home setting, and 2) their risk of MRSA

infection if they bring the patient home. Information should be conveyed to the patients family that additional infection control practices are often employed in the health care facility to reduce the risk of transmission of MRSA to the highly susceptible patients/residents, such as those with open wounds, invasive devices, or server underlying disease.

The patients family needs to understand that they rarely need to practice extraordinary infection control measures in the home beyond good handwashing and careful handling of soiled dressings. If there is a highly susceptible family member (e.g., diagnosis of cystic fibrosis, immunosuppressions, or cancer) more extensive precautions might be in order and should be discussed with a physician prior to patient discharge. INTER-FACILITY COMMUNICATION DURING ADMISSION AND TRANSFER OF THE MRSA PATIENT Communication between facilities is essential to provide information on patients being transferred so appropriate arrangements (i.e., room assignments, cohorting) can be coordinated. It is preferred practice to notify the receiving facility about a patient known to have MRSA (i.e., either colonized or infected). KEY ISSUES The following statements summarize key issues regarding discharge/admission management of MRSA patients in acute and non-acute care facilities:  Colonization with MRSA alone is not grounds for admission to a hospital.  Colonization with MRSA does not require extension of hospitalization. Arrangements for discharge to home or a non-acute care facility can proceed as the patients condition warrants. Colonization with MRSA alone should not be ground for exclusion from a non-acute care facility, if adequate facilities are available. For patients infected with MRSA, hospital discharge may occur when in the opinion of the attending physician, hospitalization is no longer required to treat a MRSA infection. A hospitalized patient colonized with MRSA may be discharged whenever he/she is medically ready. Patients infected with MRSA, who may be ready for discharge except for completion on antibiotic therapy, may be discharged to another facility, such as a long-term care facility or rehabilitation center, as long as the required care/treatment is available at that facility. The receiving facility should request and the transferring facility should provide information about the patients conditions upon transfer. This should include medical diagnoses, medications, therapies, activities of daily

living, as well as pertinent information on any infection or colonization of the patients. This information should be shard to insure appropriate and adequate care of the patients. This will also assist facilities in placing the patient in the appropriate room with appropriate roommate, and allow for any special arrangements regarding patient care.  Negative MRSA culture should note be required for transfer.