You’re off shift and enjoying your time to decompress and recharge when you notice a reddened area on your left arm about the size of a 50 cent piece. It is tender and feels warm to the touch and wasn’t there yesterday. Your first thoughts are, “Where did I pick this up? Who did I transport yesterday and what did they have? Was there anyone in the ED that was really sick?”
Unfortunately, you don’t have to look in the hospital or even the back of your ambulance to find a likely culprit. Methicillin Resistance Staphlococcus Aureus (MRSA) is now playing in your neighborhood.
Some Basics
What is Staphlococcus aureus? Staphlo (cluster or grapelike) - coccus (spherical or round) aureus (golden or yellow) is a round bacteria that huddles together, resembling a grape cluster when viewed under a microscope, and produces a golden-colored drainage during an infection.
In the past, an infection with this bacterium was easily treated with penicillin. Although bacteria don’t have an identifiable brain, they can learn. And what they learn is how to survive repeated attacks from antibiotics, developing what we call resistance. The obvious problem is the continual development of resistance against successive antibiotics. When penicillin hit the scene in 1941, the first penicillin resistant staphylococcus was reported in 1942. Methicillin was introduced in 1960 to combat the penicillin resistant staph and the first methicillin resistant staphylococcus was reported in 1961. Vancomycin is the current antibiotic choice for methicillin resistant staphylococcus aureus (MRSA) and as expected, resistance is developing.
Healthcare or Community Associated?
Initially, MRSA was acquired in a healthcare facility or caused from a health care risk factor such as a history of previous MRSA infection or colonization (the presence of bacteria in or on the body without causing an infection), history of surgery, hospitalization, dialysis or residence in a long-term facility, or presence of an invasive medical device such as a urinary catheter, central line, etc. These infections are called Healthcare Associated MRSA or HA-MRSA.
Although MRSA is not the only healthcare-associated infectious disease, our interest here is the evolving epidemic of Community Associated MRSA or CA-MRSA. This bacterium is a different strain from the healthcare acquired MRSA. It evolved out in the community, not in the hospital. High occurrences of CA-MRSA have been associated with the following set of risk factors:
- High local prevalence (is it in your neighborhood?)
- Personal history of MRSA infection or colonization
- Report of a ‘spider bite’ (patients often report MRSA as a spider bite since it can appear suddenly and is painful)
- Close contact with infected individuals
- Young age
- Crowded and/or unsanitary conditions
- Problems with your immune system (immune disease or immune suppressive drugs like prednisone or chemotherapy)
- Participation in contact sports or sharing athletic equipment or towels
- Intravenous drug abuse
- Men who have sex with men
Fortunately, CA-MRSA is sensitive to a wider range of antibiotics than HA-MRSA . . . at least for now. Unfortunately, MRSA from any source is on the march. According to data compiled from 1999 to 2005 by the Centers for Disease Control (CDC), hospitalizations and deaths from MRSA have increased significantly and “suggests that S. aureus and MRSA should be considered a national priority for disease control.”
Defense Strategy
The skin is an amazing shield against infection. Effective hand-hygiene practices help reinforce this shield against invading disease-causing-organisms (pathogens) in the field or at home base. From the CDC:
| “Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms (e.g. methicillin resistant staphylococcus aureus) and reduce overall infection rates.” |
And from the CDC concerning hand-hygiene technique:
“When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. “When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry . . .” |
Good hand-hygiene practices also include preventing skin breakdown by those frequent applications of soap and water or alcohol; thus, you may find medicated lotion soap or a separate dispenser for skin lotion at your medical facility.
One caution about those alcohol based hand rubs; don’t be surprised if your patient thinks you have been drinking on the job. A few weeks ago I went into a room to visit with a pregnant patient in early labor. On the way I grabbed a dab of the alcohol-based hand cleaner and proceeded into the room. After gathering a brief history and determining that the delivery was not imminent, I left the room to review the patient’s chart. A short time later, the nurse exited the room and on her approach, informed me that the patient had said, “The doctor should do his drinking at home!” I returned and demonstrated the alcohol-based cleaner as the culprit. However, when I began to perform a focused physical exam, her nasal breathing became more pronounced anytime my face was near hers.
Summary
With mounting resistance to antibiotics, prevention becomes even more important. Protect yourself and your family. Hand hygiene is the single most effective prevention against the spread of infection, including MRSA. Proper hand hygiene utilization and technique is just as important as your ability to discharge a defibrillator or ventilate a non-breathing patient.
http://phil.cdc.gov/phil/details.asp
Note: This is staphylococcus aureus that is methicillin resistant and is from one of the first cultures of MRSA in the U.S. that showed increased resistance to vancomycin.
References
- Talan DA, Amin AN, Deresinski SC, Moran GJ. Highlights of a Symposium, CA-MRSA On Board. Continuing Medical Education Symposium, Oct. 2007, University of Kentucky College of Medicine.
- Mark D. Community-Associated MRSA: Disparities and Implications for AI/AN Communities. IHS Primary Care Provider. 2007. Dec; 32(12): 361-365.
- Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002:51(No. RR-16).
- Klein E, Smith DL, Laxminarayan R. Hospitalizations and Deaths Caused by Methicilling-Resistant Staphylococcus aureus, United States, 1999-2005. Emerging Infectious Diseases: 2007;13: 1840-1846.
