MRSA What it is and how to control it in your facility

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MRSA What it is and how to control it in your
facility

• Robyn S. Kay, MPH
• Epidemiologist
• Bureau of Epidemiology

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Staphylococcus aureus
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Disease Manifestations due to Staphylococcus
aureus

• Skin and soft tissue infections
• Impetigo
• Cellulites
• Osteomyelitis
• Pneumonia
• Endocarditis

• Septic phlebitis
• Catheter infections
• Surgical site infections
• Toxic shock syndrome
• Septicemia
• Septic arthritis

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Staphylococcus aureus

• Staphylococcus aureus is a bacteria commonly
  found on skin of healthy people.
• It was major cause of mortality before the advent
  of penicillin.
• With the discovery of penicillin the mortality
  due to S. aureus was greatly reduced.
• Resistance to penicillin quickly developed and
  methicillin was introduced to treat penicillin
  resistant strains.
• In 1961 methicillin resistance was first
  reported.
• Methicillin Resistant S. aureus (MRSA) is now a
  global problem

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Emergence of Resistance in S. aureus
Chambers, EID 7178-182, 2001
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There is a concern that vancomycin resistant MRSA
will become established!
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Antibiotic resistant organisms have not been
shown to be more infectious nor more virulent
than susceptible organisms they are just more
difficult to treat.
Important Point
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Resistant infections areassociated with

• Increased morbidity
• Prolonged treatment and hospital stays
• Greater direct and indirect costs
• Prolonged periods in which individuals are
  infectious
• Greater opportunities for spread of infection

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ClassicalRisk Factor for MRSA

• Increased length of hospital stay
• multiple hospitalizations
• Age greater than 65
• Multiple invasive procedures
• Wounds
• Sever underlying disease
• Administration of broad spectrum antibiotics

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Healthcare-Associated MRSAHA-MRSA

• Leading cause of nosocomial pneumonia, surgical
  wound infection, and bloodstream infection
• Established risk factors include
• Current or recent hospitalization
• Recent surgery
• Residence in long-term care facilities
• Dialysis
• Invasive device use
• Typical resistance profile
• Resistant to many antimicrobials in addition to
  beta-lactams

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Community-Associated MRSA CA-MRSA

• Reports began in 1980s of MRSA occurring in the
  community in patients without established risk
  factors
• Younger patients
• Indigenous peoples and racial minorities
• Skin infections common
• Outbreaks
• Injection drug users
• Players of close-contact sports
• Prison/jail inmates
• Group Homes (developmentally disabled)
• Men who have sex with men

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N Eng J Med 2005 3521436-44
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MMWR Vol 52, No 41992   10/17/2003
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What do these outbreaks have in common?

• Crowding/Close Contact
• Poor Hygiene
• Potential for breaks in the skin integrity

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Correctional Facility A
Correctional Facility B
MRSA is an institution, community, state,
national and international problem
The Community
Health Care Facility
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Amplification
Crowding Close Contact Poor Hygiene Impaired Skin
Integrity
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Some Important Concepts

• There is no single remedy for controlling
  antibiotic resistance
• A coordinated multidisciplinary approach is
  required
• Infection control measures are essential
• Measures to limit or eliminate inappropriate
  antibiotic use must take place in order to
  control resistance

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Colonization vs. Infection

• Colonization - is the presence, growth, and
  multiplication of the organism without observable
  clinical symptoms or immune reaction
• Infection - refers to invasion of bacteria into
  tissue with replication of the organism.
  Infection is characterized by isolation of the
  organism accompanied by clinical signs of illness
  such as either fever, elevated white blood count,
  purulence (pus), pneumonia, inflammation
  (warmth, redness, swelling), etc.

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Reservoir for the Spread of Antibiotic Resistant
Pathogens
clinical infections
colonized (asymptomatic)
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Reservoirs of MRSA

• Infected individuals
• Systemic signs and symptoms of infection
• Usually requires antibiotic treatment
• Antibiotic treatment cures infection BUT does not
  eliminate carriage
• Colonized individuals
• No signs or symptoms of infection
• Silently carry MRSA
• Environment

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Presentation of MRSA

• MRSA presentation can include any of a number of
  disease manifestations
• However, the most common presentation are soft
  tissue infections such as boils, abscesses,
  furuncles, carbuncles etc.

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The diagnosis

• There are a number of infectious organisms that
  can cause skin lesions.
• The only way to determine what organism you are
  dealing with is by culturing the site.
• In addition to identification of the organism the
  laboratory report can give information on the
  antibiotics that the organism is sensitive to and
  information that may be useful in an epidemiology
  investigation.

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What is antibiotic resistances?
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Typical Antibiogram for CA-MRSA in Florida
S Sensitive R Resistant
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Dont be quick to blame spiders for those
spider bite wounds!

• Misdiagnosis of methicillin resistant
  Staphylococcus aureus (MRSA) infections as spider
  bites has been occurring throughout the United
  States.
• This misdiagnosis impedes the proper treatment of
  the infection and facilitates the spread of the
  infection.

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Spider Bites

• When questioning an individual about the spider
  bite ask if the spider was ever seen.
• So why spiders?
• In the mind of patient this may be the thought
  process involved
• The site hurts and bug and spider bites hurt
• This bite hurts a lot so it must be a spider
  bite!

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Day 9 after Bite from a Brown Recluse

• Often, the skin proceeds to peel away from the
  area around the wound, exposing the underlying
  tissues.

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MRSA Transmission

• The main mode of transmission of MRSA is via
  hands including those of the health care staff
• The infected or colonized individuals may be the
  source of transmission
• Devices, items, or environmental surfaces
  contaminated with body fluids containing MRSA

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Prevention Strategies
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Control Plan

• Have a facility infection control plan
• HAND HYGIENE / HANDWASHING
• Communications
• Follow standard precautions
• Education - Personnel, Visitors, and Family
  members

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Preventing CA-MRSA Skin Infections and
Transmission

• Ensure availability of soap and water
• Encourage good hygiene
• Discourage sharing of towels and personal items
• Establish cleaning schedules for equipment
• Cover wounds and provide wound care and dressing
  change on a set schedule
• Reduce barriers to health care clinics for
  potentially infectious disease
• Encourage the reporting of skin lesions and
  assess new individuals for skin lesions
• Regularly clean bathrooms
• Wash laundry with detergent and/or bleach in hot
  water and use hot dryer

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Standard Precautions for Health Care workers
include

• Hand hygiene / handwashing- before and after
  patient contact and after touching contaminated
  items
• Gloving - when touching blood, body fluids,
  secretions, excretions,and contaminated items
• Masking if aerosol of infectious material
  expected
• Gowning
• Appropriate handling of laundry

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Contact Precautions include

• In addition to standard precaution contact
  precautions include
• Patient Placement private room or cohorting
• Gloves when entering the room and removal before
  leaving the room
• Wear a gown when entering the room
• Limit the movement of the patient
• Use dedicated noncritical patient-care equipment

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So Why All the Fuss About Hand Hygiene?

• Most common mode of transmission of pathogens is
  via hands!

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Hand Hygiene Adherence in Hospitals

• Year of Study Adherence Rate Hospital Area
• 1994 (1) 29 General and ICU
• 1995 (2) 41 General
• 1996 (3) 41 ICU
• 1998 (4) 30 General
• (5) 48 General

1. Gould D, J Hosp Infect 19942815-30. 2.
Larson E, J Hosp Infect 19953088-106. 3.
Slaughter S, Ann Intern Med 19963360-365. 4.
Watanakunakorn C, Infect Control Hosp Epidemiol
199819858-860. 5. Pittet D, Lancet
20003561307-1312.
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Summary Alcohol-Based Handrubs What benefits do
they provide?

• Require less time
• More effective for standard handwashing than soap
  
• More accessible than sinks
• Reduce bacterial counts on hands
• Improve skin condition

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Hand Hygiene Program

• Adequate hand hygiene is the simplest effective
  infection control measure for preventing and
  containing MRSA infections!
• Periodically provided education on the importance
  of hand hygiene and effective hand hygiene
  techniques.
• It is not enough just to tell people to wash your
  hands they have to have access to soap, water and
  towels.
• The institutions hand hygiene program should be
  monitored for compliance

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Decolonization Therapy

• Decolonization is of unproven benefit in
  controlling a MRSA outbreak in the correctional
  setting and should therefore be considered on a
  case by case basis.
• Decolonization does not eradicate colonization in
  all treated person and does not prevent
  recolonization following future exposures to MRSA
  
• Decolonization is not recommended for routine
  use for MRSA.
• The overuse of mupirocin (Bactroban) has been
  associated with resistance to this agent

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The Role of the Environment in Transmission of
MRSA

• Outbreaks of MRSA have been linked to
  environmental sources
• Sanitation measures are essential for preventing
  the spread of MRSA infections and include
• Housing Areas
• Recreation Facilities
• Healthcare Units
• Laundry

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The Inanimate Environment Can Facilitate
Transmission
X represents VRE culture positive sites
Contaminated surfaces increase
cross-transmission Abstract The Risk of Hand
and Glove Contamination after Contact with a VRE
() Patient Environment. Hayden M, ICAAC, 2001,
Chicago, IL.
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Survival of Staphylococci in the Environment

• Contaminated of health care worker uniforms is
  not uncommon!
• One study found 65 of nurses who took care of
  patients with MRSA in wound or urine contaminated
  their uniforms or gowns
• Survival time of S. aureus on fabrics can be days
  to weeks

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Survival of Staphylococci on Fabric
J. Clin. Microbiol. Feb 2000 p 724-726
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Antibiotic Prescribing Practices

• Antibiotic use should be monitored for
  appropriate use
• The overuse of antibiotics especially
  broad-spectrum antibiotics should be discouraged!
  

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Screening and surveillance

• Medical intake screening should include
  evaluation for skin infections
• Bacterial cultures should be routinely monitored
• Staff should refer individuals to health
  services who have potential skin infections
• Food handles should be monitored for skin
  infections

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Transporting and Transferring Individuals With
Skin Infections

• Individuals should be fully evaluated prior to
  transfer to another institution
• Receiving institution should be fully aware of
  patients condition

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Infection Control Containment

• Individuals diagnosed with MRSA should be
  evaluated for the risk of contagion to others
• Those at high risk for infecting other should not
  be in the general population
• Individuals with non-draining lesions or draining
  lesions that can easily be contained by a simple
  dressing can be in the general population but
  MUST be education about hand-hygiene and personal
  hygiene. Compliance with good hygiene should be
  monitored.

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Environmental Control

• An EPA approved disinfectant should be used in
  cleaning environmental surfaces.
• Environmental surveillance cultures are of
  limited benefit and should not normally be done.
• Individuals with MRSA infections should have a
  separate shower and toilet if possible. If this
  is not possible surfaces should be
  decontamination prior to use by uninfected
  inmates.

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Treatment of MRSA Infections
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Management of Skin and Soft Tissue CA-MRSA
Abscesses

• Aggressive drainage of accessible fluid
  collections is essential in the treatment of skin
  lesions. MRSA infections may resolve with
  incision and drainage alone without antibiotic
  therapy.
• Treat with appropriate antibiotics. The choice
  of antibiotics should be bases on the antibiotic
  susceptibilities. Broad spectrum antibiotics
  should be discouraged.

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Antibiotic Treatment of CA-MRSA

• Bases on the antibiotic resistant patterns seen
  in Florida skin infections can be treated
  effectively with oral antibiotics such as
• trimethoprim-sulfamethozazole
• with or without
• Rifampin
• For
• 7-10 days
• Vancomycin should not be routinely given for
  MRSA!

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Outbreaks and Outbreak Management

• Definition of an MRSA outbreak includes
• Two or more cases of epidemiologicallly-related
  MRSA
• Outbreaks are suggested if similar antibiotic
  susceptibility patterns are identified among two
  or MRSA isolates

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Reporting of MRSA to the Health Department

• Single cases of MRSA are not reportable to the
  County Health Department
• Outbreaks of MRSA or any other infectious
  organism are reportable to the health department.
• The health department can assist in developing
  prevention strategies and investigating
  outbreaks.

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MRSA fingerprints from Putnam County isolates
Isolate 3
Isolate 4
Isolate 1
Isolate 2
Std.
Std.
There are three different strains that came from
this Facility. Isolate 1 and 2 share the
same MRSA strain.
FL05149 11/30/05
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Outbreak Management

• A line list should be used to track MRSA cases
• An epidemiological investigation should be
  conducted to determine if there is a common
  source among cases.
• The segregation or cohorting of cases that are
  potentially contagious should be implemented as a
  control strategy.
• Emphasis should be placed on education of
  individuals and staff.

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Education

• Education should reinforce the importance of
• Hand washing
• Good personal hygiene
• Routine showering
• Maintenance of a clean cell
• Regular laundering of bed linens
• Self-reporting of all skin lesions
• Refraining from any injection drug use, tattooing
  and sexual contact with other inmates

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Any questions?
Robyn Kay Phone [phone] Cell (850)
528-0605 Email Robyn_Kay_at_doh.state.fl.us