MRSA: An Important Healthcare Associated Pathogen

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MRSA An Important Healthcare Associated Pathogen

• Assisted Living Forum
• May, 2008

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Abbreviations/Definitions

• MRSA methicillin resistant Staphylococcus
  aureus
• MSSA methicillin sensitive S. aureus
• HA healthcare associated
• CA community associated
• Colonization organism is on or in the body but
  not causing disease
• Infection organism is present and causing signs
  and symptoms of disease

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History

• 1940s widespread use of penicillin
• 1950s Penicillin resistant SA
• 1959 methicillin introduced
• 1961 MRSA appears in UK
• 1970s MRSA in US health care facilities

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Characteristics of staph

• Gram positive cocci

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Characteristics of staph

• Reservoirs
• Skin
• Axilla
• Pharynx
• Perineum
• Nares
• Contaminated surfaces, items

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Characteristics of staph

• Causes minor infections such as pimples, boils,
  other skin conditions
• Impetigo
• Major infections include bacteremia, cellulitis,
  pneumonia, osteomylitis
• Scalded skin syndrome in newborns

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Characteristics of staph

• Food poisoning
• Toxic shock syndrome
• Major cause of hospital acquired infections

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MRSA
Methicillin resistant Staphylococcus aureus
is the form of the staph bacterium that is
resistant to a variety of antibiotics
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MRSA

• 2 types
• HA health care associated
• CA community associated

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Differences between HA and CA MRSA
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Strategies for Reducing MRSAKey concepts

• MRSA is spread by direct and indirect contact.
• Both colonized and infected persons are sources
  of transmission.
• Colonized persons are not always identified.
• Most persons with histories of MRSA are either
  permanently or intermittently colonized.

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Strategies for Reducing MRSAKey concepts
The most common way resistant organisms are
spread in health care settings is from patient to
patient via the hands of health care workers.
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Strategies for Reducing MRSATransmission in
Community Settings

• Standard precautions
• Contact precautions

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Standard precautions

• Hand hygiene
• PPE
• Laundry/linen
• Waste disposal
• Cleaning/disinfection
• Respiratory hygiene/cough etiquette
• Safe injection practices

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Hand hygiene program

• Goal is 100 compliance
• Compliance program should include ALL levels of
  staff and providers
• Include visitors, residents
• Monitor compliance
• Hold staff, providers, administrators accountable

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Hand hygiene practicesfor staff

• Use alcohol gel unless hands are visibly soiled
• Before direct contact with resident
• After contact with residents intact skin
• After contact with blood/body fluids, non-intact
  skin, mucous membranes

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Hand hygiene practicesfor staff

• Between cares from contaminated body site to
  clean body site
• After removing gloves
• After contact with inanimate objects, including
  medical equipment, in immediate vicinity of
  resident
• Before eating, after using rest room
• After sneezing, coughing into hands or tissue

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Hand hygiene practices for residents

• Promote hand hygiene in residents
• after using rest room
• after coughing/sneezing
• before eating
• before leaving their rooms
• before participating in social activities

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Personal protective equipment

• Gloves wear when hands are touching blood, body
  fluids, non-intact skin, mucous membranes
• Gowns when skin or clothing comes in contact
  with blood/body fluids
• Surgical mask/face shield/goggles when
  anticipating splashes/sprays of blood/body fluids
  to mouth, nose, eyes

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Laundry/linen

• Handle with minimum agitation
• Collect but do not sort at point of use
• Place wet laundry in leak proof bags
• Sort using standard precautions
• Launder in hot water (140ºF) and detergent or
  warm water and bleach
• Dry thoroughly in hot dryer (180ºF)

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Waste disposal

• Place contaminated sharps such as used needles,
  unused needles, broken glass vials, lancets,
  syringes with needles attached.
• Items with blood/body fluids to the point of
  being dripable, flakable, pourable, squeezable
  are placed in biohazard bags.

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Cleaning/disinfection

• Training and competency of housekeeping staff
• Monitor staff performance
• Emphasize appropriate product and contact time
• http//www.epa.gov/oppad001/chemregindex.htm
• Routine cleaning/disinfection of high touch
  surfaces/common areas

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Cleaning/disinfection

• Proper disinfection of medical equipment/patient
  care items between resident use
• Blood pressure cuffs
• Stethoscopes
• Glucose meters
• Bed pans
• Crutches

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Contact precautions

• For residents with active MRSA infections at any
  body site
• For residents with uncontrolled wound drainage or
  uncontained body fluids

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Contact precautions

• Private rooms if possible, OR
• Place in room with resident having same organism,
  OR
• Place with resident at low risk of infection

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Contact precautions

• If wound drainage/body fluids can be contained,
  resident may leave room
• Wash hands
• Wear clean clothing
• Residents with uncontained wound drainage/body
  fluids should have limited movement outside room

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Contact precautions

• Discard or disinfect medical equipment, patient
  care items, furnishings and other items in room
  before removing from the room
• Perform terminal cleaning/disinfection upon
  release from contact precautions
• Notify receiving facilities of MRSA status at
  time of transfer

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Decolonization

• Not recommended as a routine component of control
• Eradication not long-term
• Increased mupirocin resistance
• Optimum methods not established
• Decision to treat
• If individual would benefit clinically
• If ongoing transmission would be reduced
• Decision to treat HCW based on epidemiologic
  evidence

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Community Associated MRSA
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Who Gets CA MRSA

• Pacific Islanders
• Alaskan Natives
• Native Americans
• Men who have sex with men
• Military recruits
• Children
• Athletes
• INMATES

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Risk Factors

• Close skin to skin contact
• Crowded conditions
• Compromised skin
• Contaminated items
• Cleanliness (lack of)

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Treatment

• Uncomplicated infections
• Warm soaks
• Incision and drainage of abscesses
• Culture purulent material
• Antibiotic therapy
• TMP/SMX
• Tetracyclines
• Clindamycin
• Do NOT use rifampin alone, quinolones, oral
  vancomycin

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Abscess I and D

• Fitch et al. Abscess incision and drainage.
  Videos in clinical medicine. http//content.nejm.o
  rg/cgi/video/357/19/e20

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CA MRSAMain Messages

• Most infections are mild skin infections
• Infections are treatable
• There are ways to help prevent infection

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CA MRSAMain Messages

• Keep skin clean
• Hand hygiene
• Personal hygiene
• Cover wounds
• Do not touch others wounds

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CA MRSAMain Messages

• Keep skin intact
• Prevent pressure ulcers
• National Pressure Ulcer Association
• American Medical Directors Association

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MRSA

• DHFS website for MRSA resources
• http//dhfs.wisconsin.gov/communicable/MRSA/index.
  htm

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Gwen Borlaug, CIC, MPHDivision of Public
Health1 West Wilson Street Room 318Madison, WI
53701608-267-7711borlagm_at_dhfs.state.wi.us