Hospital and community aquired MRSAwp.cune.org/.../2013/01/HospitalandcommunityaquiredMRSA.docx · Web viewHospital and Community Acquired MRSA Sandra Adrianne Pena Concordia University

Running head: HOSPITAL AND COMMUNITY ACQUIRED MRSA 1

Hospital and Community Acquired MRSA

Sandra Adrianne Pena

Concordia University

Fundamentals of Public Health

MPH 500

Dr. Jen Janousek

February 24, 2013

HOSPITAL AND COMMUNITY AQUIRED MRSA 2

Hospital and Community Acquired MRSA

Staph infections were first recognized as early as the 1880s, at that time many of the

antibiotics that we depend on today did not exist and there was little that could be done by

healthcare providers at the time to treat these oftentimes painful sores that could be located in

various areas on the body. Occasionally, these infections were known to rapidly progress to

various complications such as, bacterial pneumonia, sepsis, and sometimes even death ("NIAID,"

2012). Roughly 60 years later, antibiotics like penicillin were discovered and they were quickly

proven to be invaluable in the treatment of various bacterial infections which promptly lead to

the overuse and misuse of antibiotics when they routinely began to be used for the treatment of

viral infections to which they had no benefit ("NIAID," 2012). The ramifications of the misuse

and over use of antibiotics rapidly led to antibiotic resistance which is the case with MRSA.

Methicillin-resistant Staphylococcus aureus also known as, MRSA is a, “infection caused by a

strain of staph bacteria that's become resistant to the antibiotics commonly used to treat ordinary

staph infections” ("Mayo Clinic," 2012). Because of this MRSA infections are often referred to

as a ‘super bug’.

Since it was first described in the early 1960s, “methicillin-resistant Staphylococcus

aureus (MRSA) has become a major public health issue because of worldwide spread of several

clones” (Laurent et al., 2012) that is affecting individuals all around the world.

Description

The microbiological appearance of the MRSA bacterium is, “spherical, gram-positive, and

contains a peptidoglycan layer in its cell wall, Staphylococcus aureus lacks flagella and as a


result is non-motile” (Alexander, 2010). MRSA has the appearance of a ‘bunch of grapes’ under

the microscope due to the, “activity of the coagulase enzyme” ("bioquell.com", 2012).

Habitat

The natural habitat of S. epidermidis is, “protein-rich and warm, typically on catheters, surgical

wound, synthetic knees, hips or plates, and pins at fracture sites ("eHow," 2013) which are

common in the hospital setting. S. aureus thrives in the hospital setting and are extremely

virulent, resistant to most antibiotics and disinfectants” currently in use ("eHow," 2013). Staph is

also known to thrive in, “warm, moist places; common sites of colonization include the nostrils,

belly button, underarms, and groin” (“cdc.gov,” 2012) which are common in over populated

areas within the community.

Genetic Mechanism

Resistance of MRSA has been identified as having, “High-level resistance to methicillin [which]

is caused by the mecA gene, the presence of the mec gene is an absolute requirement for S.

aureus to express methicillin resistance (Lowy, 2013) which [then] encodes an alternative

penicillin-binding protein, PBP 2a” (Wielders, Fluit, Brisse, Verhoef, & Schmitz). “HA-MRSA

and CA-MRSA differ at the genetic level and have distinct biologic properties. These differences

suggest that CA-MRSA strains may spread more easily from person to person or cause more skin


disease than HA-MRSA. At least three different strains of staph that causes CA-MRSA” (Baylor

College of Medicine, 2013). The mecA gene is part of a 21- to 60-kb Staphylococcal

Chromosome Cassette mec (SCCmec), a mobile genetic element that may also contain genetic

structures such as Tn554, pUB110, and pT181 which encode resistance to non-β-lactam

antibiotics” (Wielders et al.). “By using DNA microarray technology, mecA has been detected in

at least five divergent lineages, implying that horizontal mecA transfer has played a fundamental

role in the evolution of MRSA” (Wielders et al.)”.

Prevalence

The prevalence of MRSA in the community is predicted to increase substantially due to the

dissemination of a successful SCCmec type by horizontal transfer” (Wielders et al.). It is

estimated that, “1.5% of the U.S. population was colonized in the mose with S. Aureus and

MRSA respectively” ("cdc.gov," 2010). “The proportion of healthcare-associated staphylococcal

infections that are due to MRSA has been increasing 2% of S. aureus infections in U.S.

intensive-care units were MRSA in 1974, 22% in 1995, and 64% in 2004” ("cdc.gov," 2010).

With more that 14 million outpatient cases of S. aureus skin and soft tissue infections in the

community setting in 2005 alone the urgency for identifying effective treatment is rapidly

increasing ("cdc.gov," 2010). As HA and CA- MRSA continue to be studied many studies have

been completed one of which was by the association for Professionals in Infection Control and

Epidemiology which determined that, “70% of the isolates reported were likely to be HA-

MRSA, and approximately 30% were more consistent with CA-MRSA. Further stating, that

although CA-MRSA has received enormous recent media attention and the attention of many

researchers, HA-MRSA continues to account for the majority of the MRSA burden in US Health

care facility inpatient”(Jarvis, Schlosser, Chinn, Tweeten, & Jackson, 2007).


Resistance

Many have questioned why MRSA has been able to take such an unforgiving hold on society and

affect and take so many lives and many believe that it is because the overuse of antibiotics.

Antibiotics have been hailed for the countless lives that have been saved over the last 70 years,

but resistance is becoming more and more common which is consequently affecting the way

patients with staph infections are being treated. A diagnosis of MRSA is made after an individual

does not respond to the first line antibiotic course that would normally treat and cure a staph

infection ("NIH," 2012). Antibiotics that MRSA is resistant now includes penicillin, this is

because, “Staphylococcus aureus can make a substance called ß-lactamase, that degrades

penicillin, destroying its antibacterial activity” (Johnson, 2007).As, “resistance to methicillin is

determined by the mecA gene, which encodes the low-affinity penicillin-binding protein PBP 2A.

This knowledge reinforces the belief that antibiotic resistance is due to the over use and misuse

of antibiotics has become a real problem that is currently lacking viable solutions to

[substantially] decrease the rate at which MRSA infections are occurring. This phenomenon of

antibiotic resistance is causing providers to get more aggressive and creative with the treatment


of their patients leading to increased hospital stays and a general increase in hospital costs for

patients and insurers alike. The antibiotic treatment of MRSA falls heavily upon the use of

Penicillin and other –cillin drugs until like other drugs resistance was developed. Today,

“Vancomycin, teicoplanin and fosfomycin, and new MRSA-active antibiotics including

quinupristin/dalfopristin, linezolid and daptomycin. The most widely used of these

is Vancomycin, which is known as a glycopeptide antibiotic. Taken orally, Vancomycin only

works in the intestines to control infection there. For other areas of infection, Vancomycin must

be taken via injection. The drug is a rough ride. Symptoms of Vancomycin can include nausea,

dizziness, feeling cold, flushing, pain, muscle spasms, bruising, the development of a rash,

ringing in the ears, hearing difficulties, and breathing problems” (Kilham, C., 2012).

Staph infections are likely to occur in one of two environments: Hospitals and

communities:

Hospital Acquired (HA-MRSA)

Hospital acquired methicillin-resistant Staphylococcus aureus is where by far the most MRSA

vicious of the two infections are currently occurring. These infections are found in individuals

who have been in hospitals or other health care settings, when infection occurs in these settings,

it's known as, “health care-associated MRSA. HA-MRSA infections typically are associated with

invasive procedures or devices, such as surgeries, intravenous tubing or artificial joints ("Mayo

Clinic," 2012). Currently, the number of hospital acquired cases of MRSA vastly outnumbers the

number of community acquired cases.

Community Acquired (CA-MRSA)

The second location where MRSA has been identified is within the community and is referred to

as community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and is defined


as, “a MRSA-positive specimen [that] was obtained outside the hospital setting or within two

days of hospital admission, and if it was from a person who had not been hospitalized within two

years before the date of MRSA isolation” ("CDC," 2012).Currently in the, “United States, it is

believed that 28% of community-acquired S. aureus strains are resistant to methicillin”

(Wielders et al.).

As agencies around the world continue to study various components of Staphylococcus

aureus (S. aureus) in attempts to find ways to decrease the current infection rates of S. aureus as

it is becoming an frighteningly common type of bacteria that is becoming increasingly difficult

to treat. In about, “one out of every four healthy people, the staph germ lives on the skin or in the

nasal passages, but it does not cause any problems or infections. These people are said to be

colonized with staph” ("Mayo Clinic," 2012). “Colonization is the presence of the bacteria, but

no acute signs of illness or infection” (Virginia Department of Health [VDH], 2012). In

approximately, “1-2 % of those who are colonized will proceed to infection; infection is the

clinical signs of illness or inflammation due to tissue damage caused by invasion by the bacteria.

Infection requires treatment” (VDH, 2012).

For many the initial presentation of MRSA is likely to begin as, “pustules or boils

which

often are red, swollen, painful, or have pus or other drainage. They often first look like spider

bites or bumps that are red, swollen, and painful. These skin infections commonly occur at sites

of visible skin trauma, such as cuts and abrasions, and areas of the body covered by hair”

("CDC," 2012). Those that are diagnosed with this disease process are likely to experience a

gamete of other symptoms as well because symptoms vary depending on the type and stage at

which the infection is identified. With severe infections an individual may present with fever,


severe pain, abnormal blood counts, and/or foul odor at the infection site. It is advised that

individuals seek medical care and treatment when individuals believe that a minor wound

becomes infected and it is firmly stated and reiterated that individuals not attempt to treat these

infections by themselves as it increases the possibility worsening an existing infection while

increasing the probability of spreading infections to other individuals. ("CDC," 2012)

As HA and CA-MRSA occur in different settings, “the risk factors for the two strains

differ” ("Mayo Clinic," 2012) as well.

Social and behavioral risk factors for HA-MRSA

Individuals are at an increased likelihood of developing a case of HA-MRSA are as expected

being hospitalized because individuals within hospitals have a tendency suppressed or

compromised immune systems. Additionally, those that have invasive medical device like

medical tubing such as intravenous lines or urinary catheters. Lastly, those who reside in long

term care facilities because MRSA is usually prevalent in these locations because of the presence

of both suppressed immune systems and the use of invasive medical devices ("NIH," 2012).

Risk factors for CA-MRSA

Include participation in contact sports such as football, basketball, and wrestling, since MRSA

can easily travel though cuts and abrasions that are likely to occur during contact sports. Also,

those living in crowded or unsanitary conditions like those common in military training camps

and jails have been linked to increased occurrence of MRSA. Lastly, it is thought that men who

engage in homosexual activities are at an increased risk of developing.

Prevention

As with all prevalent disease processes prevention is the number one factor that can make a

dramatic difference in these currently staggering statistics, if the overall incidence of infection


begins to decrease other complications associated with MRSA infections are likely decline as

well including healthcare costs and mortality statistics. The prevention techniques that can be

used to combat the rising numbers of MRSA infections relies heavily on individuals maintaining

high levels of personal prevention practices which includes appropriate hand-washing

techniques, not sharing personal items like razors, keeping wounds clean and covered, and

avoiding contact with individuals that may have wounds or soiled bandages if appropriate

personal protective equipment is not available ("CDC," 2012). Other considerations should be

taken into account in specific locations when contacts with contaminated surfaces are more

likely. These specific locations include schools, athletic facilities, and correctional institutions.

The introduction of alcohol-based hand gels and sanitizers have been able to for improved hand

hygiene on-the-go. However, reducing the spread of MRSA within hospital settings has proven

to be quite difficult (Alexander, 2010).

Prevention has proven to be very useful in the efforts to combat the spread of MRSA, but

testing and diagnosis measures still remain essential as the first step utilized by healthcare

providers when determining what microorganism they are dealing with.

Diagnosis

Regardless of the strain MRSA diagnosis is made by checking a, “tissue sample or nasal

secretions for signs of drug-resistant bacteria” ("Mayo Clinic," 2012). After a sample is obtained

it is promptly sent to a laboratory where the sample can be placed in a, “dish of nutrients that

encourage bacterial growth” ("Mayo Clinic," 2012) but, for those samples to grow appropriately

they require a minimum of 48-hours, which could leave a critical patient in a very precarious

situation. Everyday newer methods are being identified to expedite the identification of MRSA

infections within patients; one of those methods is a, “test that can detect staph DNA in a matter


of hours” ("Mayo Clinic," 2012) which is quickly gaining popularity in the medical community

nationwide.

It is estimated that, “MRSA is responsible 19,000 U.S. deaths and 368,000

hospitalizations per year” (Pew Health Group [PEW], n.d.). In the United States in 2003, there

were an estimated, “12 million doctor or emergency room visits for skin and soft tissue

infections suspected to be caused by Staph aureus” (Moore, 2013) which has encouraged the use

of antibiotics as the course of treatment leading to antibiotic use and misuse since. “In hospitals,

190 million doses of antibiotics are administered each day. Among non-hospitalized patients,

more that 133 million courses of antibiotics are prescribed by doctors each year. It is estimated

that 50 percent of the latter prescriptions are unnecessary” (American College of Physicians

[ACP], 2013). As the practice of prescribing unnecessary prescriptions has continued to raise

throughout the years the increasing number of patients being hospitalized with MRSA infections

has mirrored the lack of viable treatment options. In 2003, “about 21 out of every 1,000 patients

hospitalized to about 42 out of every 1,000 in 2008, or almost 1 in 20 inpatients” ("The

University of Chicago Press ," 2012). MRSA infections is an extremely concerning to patients,

healthcare providers, and insures alike as the “annual cost to treat patients with MRSA patient

are between $3.2 billion and $4.2 billion in the United States alone” (PEW, n.d.). It is estimated

that on average, [an] “uninsured family can only afford to pay in full for about 12% of any

hospitalizations they might experience (Assistant Secretary for Planning and Evaluation

[ASPE], 2011). Therefore those, “lacking health insurance poses a greater risk of financial

catastrophe than lacking car insurance or homeowner’s insurance” (ASPE, 2011) patients inside

and outside of hospitals and healthcare facilities alike when MRSA infections were at their peak.


HOSPITAL STAYS WITH MRSA INFECTIONS

(1993–2005)

It is said tha the high costs associated with MRSA infections, both monatary and

emotinally should be more than enough to instate stringent infection control programs within

healthcare facilites that will aid in combating the rising numbers of hospital aquired cases of

infectious diseases (Hannah, 2005). As the number of cases of HA-MRSA increased agressive

hand-washing and gel-in/gel-out programs have been instated in healthcare facilities around the

country consequently leading to an increase in, “Hand hygiene compliance rates from a baseline

compliance of 49% to 98%”, therefore the improvements in hand hygiene compliance among

patients, visitors, and staff has translated into a notable decrease in the number of hospital-

acquired MRSA infections as statistics showed that the number of hospital acquired infections

went from, “0.52 per 1,000 patient days in 2005 to 0.24 per 1,000 patient days by year-end 2008”

(Lederer Jr, Best, & Hendrix, 2009).

With heightened awareness about the increasing commonness of HA and CA-MRSA

everyone is making increased efforts to clean and sanitize areas that are likely to have been


contaminated by MRSA organisms. Cleaners that are used to remove dirt and germs from

surfaces by rinsing them away with the routine cleaning of the surfaces are marginally effective.

Also, sanitizers that reduce germs on surfaces, like hands are very effective, but do not

completely get rid of germs. Lastly, disinfectants which are chemical products that are used to

destroy or inactivate germs consequently, preventing them from growing further are regulated by

various agencies but are common for use on inanimate objects and surfaces that are visibly soiled

with blood or other secretions ("CDC," 2012)

As the spread of MRSA initially skyrocketed, then tapered slightly, before finally starting

to decrease to some degree it is apparent that progress is being made. These victories can only be

attributed to diligence by healthcare workers to abide by infection control guidelines and policies

and by the educational efforts that continue to be made by health educators and providers and

lastly credible information that is constantly being provided and updated by governmental

agencies like The Centers for Disease Control and Prevention (CDC) and the National Institute

of Health (NIH).

Development of antibiotic resistance

In the late 1940s, “medical treatment for S. aureus infections became routine and

successful with the discovery and introduction of antibiotic medicine, such as penicillin”

("NIAID," 2012). From that point on, however, use of antibiotics began to be taken for granted

and subsequently used for a gamete of conditions to which antibiotics proved to be ineffective.

The reoccurrence of misuse lead to bacterial evolution which assisted, “the microbes to become

resistant to drugs designed to help fight these infections” ("NIAID," 2012). The first line of

drugs that S. aureus developed resistance to was penicillin. Methicillin, a form of penicillin, was

introduced to counter the increasing problem of penicillin-resistant S. aureus. Methicillin was


one of the most common types of antibiotics used to treat S. aureus infections; but, in 1961 the

first strains of S. aureus bacteria that resisted methicillin was discovered leading to the birth of

MRSA. It took nearly seven years for the first reported case of MRSA in the United States and

from that many other new and increasingly resistant strains are emerging. MRSA is actually

Resistant to an entire class of penicillin-like antibiotics that includes penicillin, amoxicillin,

methicillin, and other –illin drugs ("NIAID," 2012). With resistance developing against many -

illin drugs , this caused physicians to begin to rely heavily on vancomycin which is classified as

a last resort drug of sorts because it is known to kill everything, good and bad. But even

vancomycin could not avoid resistance forever and as early as 10 years ago S. aureus has begun

to show resistance to vancomycin as well, however these cases still remain rather rare ("NIAID,"

2012).

It is clear that MRSA is a problem that continues to cause numerous problems for the

medical community, insurers, and patients alike. Short term solutions have been found to be

effective and through aggressive hygiene and sanitation campaigns and studies show that the

problem has stabilized and has even began to degrease in frequency. But, the greatest solution to

the problem remains in the ability to educate the community at large to the causes of MRSA and

prevent huge and costly problems like MRSA from occurring in the first place. Providers and

patient need to be made increasingly aware of the harm that antibiotics can cause when they are

abused and misused by doctors and patients. Antibiotics are frequently started and never

finished, used when not need, or even used when expired or prescribed to someone else, these

reoccurring abuses are the root of this problem. Hopefully, as more and more people become

aware of the problem that can potentially be caused by antibiotic misuse everyone will not jump


to using antibiotics or prescribing every time a case of the sniffles begins or because it is what

the patient wants or feels is necessary.


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Hospital and community aquired MRSAwp.cune.org/.../2013/01/HospitalandcommunityaquiredMRSA.docx · Web viewHospital and Community Acquired MRSA Sandra Adrianne Pena Concordia University