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Methicillin-resistant Staphylococcus Aureus (MRSA) ICD9:

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1 Methicillin-resistant Staphylococcus Aureus (MRSA) ICD9: 038.12
Melissa Wilson RN BSN FNP-S

2 Definition Methicillin-resistant Staphylococcus Aureus (MRSA) is a type of staph bacteria that is resistant to certain antibiotics called beta-lactams. These antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin, and amoxicillin. In the community, most MRSA infections are skin infections. More severe or potentially life-threatening MRSA infections occur most frequently among patients in healthcare settings. While 25% to 30% of people are colonized* in the nose with staph, less than 2% are colonized with MRSA. (Gorwitz, 2008)

3 Defining Colonization
You can be "colonized" with MRSA, meaning that you carry the bacteria on your skin or in your nose but you have no signs or symptoms of the illness. Staphylococcus aureus is a bacterium that lives normally on human skin surfaces – in fact 40% of us have the little guys all over us right now as we sit here in front of our computers. MRSA, which is simply an antibiotic resistant strain of Staphylococcus aureus, can also live on our skin for long periods or even permanently without us ever knowing it. This is called colonization, and depending on the population group/risk profile most studies show that 5-10% of us are carrying MRSA around with us wherever we go. Up to date, 2013

4 Defining Colonization
As far as sites of colonization these bacteria can live on virtually any skin surface, but they really love the warmest, dampest, darkest areas they can find including the nose, throat, armpits, and various sites “south of the border”. It is widely accepted in the medical community that the nose represents the primary reservoir of S. aureus/MRSA colonization in humans, with the throat emerging as another important area and all other sites considered secondary. (Street, 2010)

5 Defining: HA-MRSA Versus CA-MRSA
Hospital Acquired MRSA (HA-MRSA) has a distinct difference from Community Acquired MRSA (CA-MRSA) Current evidence indicates that these CA-MRSA strains are genetically distinct from hospital-acquired MRSA (HA-MRSA), and that several unique community-acquired clones emerged simultaneously in different locations in the world (Vandenesch, 2003). CA-MRSA infections occur in otherwise healthy people without traditional risk factors

6 HA-MRSA versus CA-MRSA
CA-MRSA cause a different spectrum of illness than HA-MRSA, and some CA-MRSA strains may be more virulent. CA-MRSA frequently causes skin and soft tissue infections (SSTI), however, CA-MRSA also can be associated with severe invasive disease (e.g., bacteremia/sepsis syndrome, pneumonia, pyomyositis, bone and joint infections, endocarditis, necrotizing fasciitis) (Naimi, 2003) Two genes are unique to CA-MRSA isolates and shared by isolates from three continents: a type IV SCCmec cassette and the PVL locus (Panton-Valentine leukocidin). CA-MRSA have different antibiotic susceptibility patterns from HA-MRSA; CA-MRSA are resistant to methicillin but generally are not multi-drug resistant. Many are sensitive to trimethoprim-sulfamethoxazole, clindamycin, aminoglycosides and quinolones. (Naimi, 2003)

7 Pathophysiology The organism may cause disease through tissue invasion and toxin production. The toxins liberated by the organism may have effects at sites distant from the focus of infection or colonization. The organism is then disseminated via hand carriage to body sites where infection may occur (either through overt breaks in dermal surfaces, such as vascular catheterization or operative incisions, or through less evident breakdown in barrier function, such as eczema or shaving-associated micro-trauma). NIH, 2008

8 Pathophysiology Beta-lactam antibiotics inhibit the growth of sensitive bacteria by inactivating enzymes located in the bacterial cell membrane, which are involved in the third stage of cell wall synthesis. It is during this stage that linear strands of peptidoglycan are cross-linked into a fishnet-like polymer that surrounds the bacterial cell and confers osmotic stability in the hypertonic milieu of the infected patient. Beta-lactams inhibit not just a single enzyme involved in cell wall synthesis, but a family of related enzymes (four to eight in different bacteria), each involved in different aspects of cell wall synthesis. These enzymes can be detected by their covalent binding of radioactively-labeled penicillin (or other beta-lactams) and hence have been called penicillin binding proteins (PBPs). Methicillin-resistant Staphylococcus is a virulent strain of S.aureus that disinhibits the effects of beta-lactams on this particular bacterium (National Institute of Health [NIH], 2008, p ).

9 Etiology  Methicillin-resistant Staphylococcus aureus has resulted from decades of prescribed antibiotics for treatment when unnecessary. For many years, prescriber’s have treated colds, flu and other viral infections with antibiotics that do not respond to these medications. Even when antibiotics are prescribed appropriately there is a contributory rise in drug-resistant bacteria because the antibiotics do not destroy all of the germs that the drug is targeting. Bacteria are evolutionary organisms that learn to survive treatment of one antibiotic and learn to resist others (“MayoClinic,” 2013).

10 Incidence The most recent statistics find that the in 2011 there were 80,500 cases of infections in the United States as opposed to 111,300 in the year 2005. Overall the serious diagnosed cases in the hospitals dropped by 54% between the years In the year 2005 there were 9.7 cases per 100,000 and in the year 2011 there were only 4.5 cases per 100,000. Incidence of individuals developing MRSA after being discharged from the hospital or being associated with a healthcare facility fell 28% during that same Seaman, 2013

11 Incidence In 2005 there were 21 infections per 100,000 and in 2011 there reported cases were 15 per 100,000. In the development of CA-MRSA the cases reported in 2011 were estimated at 16,560 and were an average of 5.32 patients per 100,000. It is difficult to track the number of CA-MRSA because many of the cases go unreported ( Seaman, 2013

12 Risk Factors HA-MRSA Being hospitalized. MRSA remains a concern in hospitals, where it can attack those most vulnerable — older adults and people with weakened immune systems. Having an invasive medical device. Medical tubing — such as intravenous lines or urinary catheters — can provide a pathway for MRSA to travel into your body. Residing in a long-term care facility. MRSA is prevalent in nursing homes. Carriers of MRSA have the ability to spread it, even if they're not sick themselves. Mayo Clinic, 2013

13 Risk Factors CA-MRSA Participating in contact sports. MRSA can spread easily through cuts and abrasions and skin-to-skin contact. Living in crowded or unsanitary conditions. Outbreaks of MRSA have occurred in military training camps, child care centers and jails. Men having sex with men. Homosexual men have a higher risk of developing MRSA infections. Mayo Clinic, 2013

14 Clinical Presentation
Depends on the site infected: Skin: Swelling, erythema, pain, purulent drainage, pus, fever, inflammation, necrosis, boils, bullae, furuncles, carbuncles, folliculitis and abscesses. Rash may appear as broken blood vessels under the skin. Joints: Redness, warmth, swelling, pain and fever, pain worse with movement, and inability to move the joint Lungs: Fever, cough, yellow/green/tan sputum, shortness or breath, painful breathing and pleuritic pain, N&V, weakness, fatigue, tachycardia, body aches, and rapid breathing. Heart: Anorexia, back pain, fever, excessive sweating at night, weight loss, rapid pulse, rash, headache, malaise and fever. Bone: Pain, tenderness, chills, fever, swelling, redness and bone tenderness. Blood: Sepsis, anorexia, fever, muscle aches, fatigue, SOB, rapid respirations and pulse, rash, confusion and coma. Epocrates, 2013

15 Differential Diagnoses
MRSA. The differential diagnosis for MRSA are as follows: Animal or human bites, perianal abscess, brain abscess, Cellulitis, septic arthritis, Decubitus Ulcer, Pinal cord abscess, Diabetic Ulcer, streptococcus infections, liver abscess, urinary tract infections and myocardial abscess, wound infections osteomyelitis, Pneumonia Sepsis MD Guidelines, 2013

16 Social/Environmental Considerations
HA-MRSA. In the hospital, people who are infected or colonized with MRSA often are placed in isolation as a precaution to prevent the spread of MRSA. Visitors and health care workers caring for people in isolation may be required to wear protective garments and must follow strict hand hygiene procedures. Contaminated surfaces and laundry items should be properly disinfected. Social isolation can have an impact on the patients self image. CDC, 2013

17 Social/Environmental Considerations
CA-MRSA: These community-associated MRSA (CA-MRSA) infections have been identified in a variety of populations, including: athletes participating in close contact sports, military recruits in barracks settings, intravenous drug users, men who have sex with men, tattoo recipients, religious community members, and inmate populations. Moreover, many healthy adults and children—without any obvious risks for exposure—are also developing MRSA infections. In most communities in the U.S., MRSA is the leading cause of skin and soft tissue infections (SSTIs) among persons seeking emergency care ( BOP, 2012, p. 1).

18 Diagnostic Testing The way to screen for MRSA is through cultures and biopsies of the infected area. If the patient develops a skin infection screening is done by taking a culture of the infected area. Suspicion of a respiratory infection or pneumonia a sputum culture is obtained. Often blood cultures are obtained when septicemia is suspected and aseptic technique is used to obtain a urine culture. Individuals who are at risk for developing MRSA or have a history of MRSA are often screened prior to hospitalizations or surgical procedures. Up to Date, 2013

19 Distinguishing between HA-MRSA and CA-MRSA
CA-MRSA can be distinguished from HA-MRSA by using the following criteria: Diagnosis of MRSA is made in the outpatient setting or by a culture positive for MRSA within 48 hrs. of hospital admission, AND The patient has no past medical history of MRSA infection or colonization, AND The patient has no past medical history in the past 1 year of: Hospitalization Admission to a nursing home, skilled nursing facility, or hospice Dialysis Surgery Permanent indwelling catheters or percutaneous medical devices Naimi,2008

20 Management and Treatment Guidelines Non-pharmacological
Keep your hands clean by washing thoroughly with soap and water or using an alcohol-based hand rub. Keep cuts and scrapes clean and covered with a bandage until healed, avoid contact with other people’s wounds or bandages, maintain a clean environment washing surfaces that come into contact with your skin and avoid sharing personal items such as towels or razors (CDC, 2013).

21 Management and Treatment Guidelines: Pharmacological HA-MRSA
Hospitalized people with MRSA infections are usually treated with an intravenous medication. The intravenous antibiotic is usually continued until the person is improving. In many cases, the person will be given antibiotics after discharge from the hospital, either by mouth or by IV. This may be needed for a short period of time or for as long as six to eight weeks. Intravenous antibiotics can be given at home, by a visiting nurse, or in a rehabilitation facility. Nares may be swabbed with topical Mupirocin if patient is positive for MRSA in the nose. CDC, 2013

22 Management Treatment guidelines Pharmacological CA-MRSA
Treatment of MRSA at home usually includes a seven to 10 day course of an antibiotic (by mouth) such as trimethoprim-sulfamethoxazole (brand name: Bactrim), clindamycin, minocycline, or doxycycline. In addition to antibiotics, your healthcare provider may drain the infected area by inserting a needle or making a small cut in the skin. This is done to reduce the amount of infected material (pus), which will help the tissue to heal. In some cases additional strategies may be used for management of household spread and/or recurrent infection. These may include use of mupirocin ointment, chlorhexidine soap, and other techniques. These strategies are not always fully effective. CDC, 2013

23 Complications Defining MRSA complications is complex because it is dependent on the system that it affects. MRSA infections can resist the effects of many common antibiotics, so they are more difficult to treat. This can allow the infections to spread and sometimes become life-threatening. MRSA infections may affect your: bloodstream, lungs, heart, bones and joints and potentially be fatal ("Mayo Clinic," 2013).

24 Complications Necrotizing Fasciitis: Skin swelling and redness
Drainage from the skin: Skin discoloration Red or brown fluid draining from the skin Skin may turn black Pus draining from the skin Skin blisters: May appear as purple or blood*filled blisters Fever Weakness and fatigue Severe skin pain Anorexia Muscle pain Rapid pulse Severe swelling beneath the skin Malaise MD Guidelines, 2013

25 Necrotizing Fasciitis
Google Images, 2013

26 Follow up/Referrals Follow up will be different dependent on how serious the MRSA infection is. Patients who are treated in the hospital may be sent home with on IV antibiotics or oral antibiotics and will be followed up weekly. Follow up with Infectious Disease (ID) may be necessary. Patients with CA-MRSA may be treated with topical ointments, surgical incisions and oral antibiotics. These patients are followed up after 7-10 days. Surgical consult may be necessary for SSTI’s and non-healing wounds for debridement.

27 Education/Counseling
Contact your health care provider if you think you have an infection so it can be treated quickly. Finding infections early and getting care will decrease the chance that the infection will become severe. Signs of infection include redness, warmth, swelling, pus, and pain at sites where your skin has sores, abrasions, or cuts. Sometimes these infections can be confused with spider bites. Infections can also occur at sites covered by body hair or where uniforms or equipment cause skin irritation or increased rubbing. Do not try to treat the infection yourself by picking or popping the sore. CDC,2013

28 Education and Counseling
Cover possible infections with clean, dry bandages until you can be seen by a doctor, nurse, or other health care provider such as an athletic trainer. Cover your wounds. Keep wounds covered with clean, dry bandages until healed. Follow your doctor’s instructions about proper care of the wound. Pus from infected wounds can contain MRSA so keeping the infection covered will help prevent the spread to others. Bandages and tape can be thrown away with the regular trash.   CDC,2013

29 Education and Counseling
Clean your hands often. You, your family, and others in close contact should wash their hands often with soap and water or use an alcohol-based hand rub, especially after changing the bandage or touching the infected wound. Do not share personal items. Personal items include towels, washcloths, razors, clothing, and uniforms. Wash used sheets, towels, and clothes with water and laundry detergent. Use a dryer to dry them completely. Wash clothes according to manufacturer’s instructions on the label. CDC,2013

30 Questions. MRSA describes a specific type of bacteria that are resistant to certain antibiotics. True or False Is MRSA contagious? Yes or No A commonly used word to describe MRSA is... a) Superbug b) E coli c) Salmonella d) Rash 1). TRUE: Methicillin-resistant Staphylococcus aureus (MRSA) is a type of staph bacteria that is resistant to certain antibiotics, including methicillin, oxacillin, penicillin, and amoxicillin. 2). YES: MRSA is highly contagious and anyone can get it. You can get MRSA the same way you can get a cold, such as by touching someone or something that has Staph bacteria on it and then touching your eyes, nose, or any scrape or abrasion on your skin. 3). A: MRSA is often referred to as a "superbug," which is a nonspecific word that is used to describe any microorganism that is resistant to at least one or more commonly used antibiotics. MRSA Infection,2013

31 Questions 4. MRSA bacteria are most likely found... a) The community b) The hospital 5) Some of us carry MRSA bacteria in our... a) Mouths b) Noses c) Eyes d) Throats 6) What is the best defense against MRSA? a) Good hygiene b) Vaccines c) Avoiding antibiotics d) All the above 4). B: In U.S. hospitals, MRSA causes more than 60% of Staph infections. Additionally, MRSA outbreaks occur in diverse types of people who are constantly in close contact, such as team players of contact sports, dormitory residents, inmates, and armed-services personnel. 5). B&D: Approximately 25%-30% of us have Staph bacteria in our noses.6). A: The best defense against MRSA is good hygiene (especially hand washing). Note: There is no vaccine against MRSA.). MRSA Infection,2013

32 Questions 7). MRSA most often enters the body through droplets from coughing or sneezing. True or False 8). MRSA can cause sepsis, which is an infection of the blood. True or False. 9). A MRSA skin infection can often mimic a ________________. a) cut b) Scrape c) Spider bite d) Stye 10). MRSA infections can cause complications such as... a) “flesh eating” disease b) Pneumonia c) Death d) All of the above 7). False: MRSA most often enters the body through a cut or wound by direct contact. The key to preventing MRSA infections is for everyone to practice good hygiene: - Keep your hands clean by washing thoroughly with soap and water or using an alcohol-based hand rub - Keep cuts and scrapes clean and covered with a bandage until healed - Avoid contact with other people's wounds or bandages - Avoid sharing personal items such as towels or razors 8) Severe cases of MRSA can result in MRSA spreading into the blood and causing sepsis. The term sepsis is often used interchangeably with septicemia, a serious, life-threatening blood infection that progresses very quickly and is often fatal. True: 9). C:MRSA most often appears as a skin infection, like a boil or abscess. Many people who actually have a Staph skin infection often mistake it for a spider bite. 10). D:Staph infections are known to cause pneumonia. In rare cases, a MRSA infection can be serious or fatal. Very rarely, Staph can result in necrotizing fasciitis, or "flesh-eating" bacterial infections. These are serious skin infections that spread very quickly. MRSA Infection,2013

33 References Anthony Harris. (2013). Patient Information:Methicillin-resistant Staphylococcus aureus (MRSA) (Beyond the Basics). Retrieved from Epocrates Online. (2013). MRSA. Retrieved from /MRSA/Basics/Etiology Evans, R. P. (2008). The Silent Epidemic:CA-MRSA and HA-MRSA. Retrieved from Federal Bureau of Prisons Clinical Practice Guidelines. (2012). Management of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections. Retrieved from MD Guidelines. (2013). Methicillin Resistant Staphylococcus Aureus (MRSA). Retrieved from MRSA. (2013). Retrieved from /MRSA/Basics/Etiology MRSA Infection. (2013). Retrieved 10/22/2013, from MRSA infection. (2013). Retrieved from Mandal, A. (2013). What is Staphylococcus Aureus? Retrieved October 28, 2013, from Mayo Clinic. (2013). MRSA Infection. Retrieved from Methicillin Resistant Staphylococcus Aureus (MRSA). (2009). Retrieved from

34 References Methicillin-resistant Staphylococcus Aureus (MRSA) Infections. (2013). Retrieved from Methicillin-resistant Staphylococcus Aureus (MRSA) Infections:Diagnosiing and Testing MRSA Infections. (2013). Retrieved from Naimi, T. S., LeDell, K. H., & Cosmo-Sabetti, K. (2010). Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA., 10;290(22)(), Retrieved from National Institute of Health. (2008, July 16,2008). Pathogenesis of Methicillin-resistant Staphylococcus Aureus Infection. United States National Library of Health. Seaman, A. M. (2013). Hospital-acquired MRSA Infection Rates Falling: CDC. Retrieved from The Infectious Diseases Society of America. (2011, January 4, 2011). Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-resistant Staphylococcus Aureus Infections in Adults and Children. IDSA Guidelines, /cid/ciq146 Understanding MRSA; Diagnosis and Treatment. (2013). Retrieved October 23, 2013, from Vandenesch, F., Naimi, T., & Enright, M. (2003). Community-acquired Methicillin Resistant Staphylococcus aureus Carrying Panton-Valenitine Leukocidin Genes:World wide emergence. Emergency Infectious Disease, 9(), and Antibiotic Resistance by Bacteria . Retrieved from

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