Methicillin-resistant Staphylococcus Aureus (MRSA)

1. Methicillin-resistant Staphylococcus Aureus (MRSA) Megan Shrum Concordia University

2. What Is MRSA? • Methicillin-resistant Staphylococcus Aureus: • Potentially fatal staph bacterium that commonly causes skin infections. • Challenging to treat because of its resistance to certain antibiotics including methicillin, oxacillin, penicillin, and amoxicillin. (CDC, NCEZID, DHQP, 2012). • Occur in both the community and healthcare setting.

3. Public Health Domains • Epidemiology • Environmental Factors • Biostatistics • Biomedical Factors • Social & Behavioral Factors • Health Policies

4. Epidemiology • MRSA can affect anyone in any given setting. • Historically, infections were commonly found in hospitalized patients • Now we are seeing more infections occurring within our communities • People who are living in crowded living conditions are more susceptible to MRSA • Those with weakened immune systems are more susceptible • Athletes who participate in sports which involve physical contact are more susceptible • Patients in healthcare facilities, who undergo procedures and have weakened immune systems, are at greater risk (Pastagia, Kleinman, Lacerda de la Cruz, Jenkins, 2012).

5. Epidemiology continued… • Infections occur through • Indirect and direct contact with the bacteria • Skin-to-skin contact • Through Exposed wounds (Pastagia, Kleinman, Lacerda de la Cruz, Jenkins, 2012). • Common MRSA infections include surgical wound infections, urinary tract infections, bloodstream infections, and pneumonia (CDC, NCEZID, DHQP, 2012). • MRSA can cause hemorrhagic-necrotizing pneumonia and possibly death (Aldabagh, Tomecki, K. J, 2010).

6. Soft tissue mrsa infections • Soft tissue MRSA infections: • abscesses, • boils, • Cellulitis • folliculitis. (Aldabagh, Tomecki, K. J, 2010).

7. Epidemiology: STATISTICS • Healthcare onset: • Infections which began in hospitals, declined 28% from 2005 through 2008. • A 17% drop in invasive MRSA infections that were contracted outside the hospital within patients who recently left the hospital • Bloodstream infections within hospitalized patients has dropped 50% from 1997 to 2007 • Community Onset: • Infections within the community are increasing rapidly throughout the last decade. (CDC, NCEZID, DHQP, 2012)

8. CA= community associated HACO=healthcare-associated community-onset HO=hospital onset

9. Environmental Factors • MRSA infections can occur in any geographic location, on any part of a person’s body and can affect anyone(Pastagia, Kleinman, Lacerda de la Cruz, Jenkins, 2012). • Are seen in both community and healthcare settings

10. Environmental Factors: Facilities that are more susceptible to Mrsa contaminations • Athletic facilities • Dormitories • Military barracks • Correctional facilities • Daycare centers • Prisons • Facilities that experience crowded living • Athletes may spread MRSA through their locker rooms in the showers, in whirl pools, through contact with each other and athletic equipment (CDC et al., 2012).

11. Biostatistics Active Bacterial Core surveillance (ABCs) • Provides CDC and laboratories with demographic information and bacterial isolates • Studies risk factors, evaluates vaccine effectiveness, and monitoresthe effectiveness of prevention policies. (NCIRD, DBD, 2012). Health departments, individual hospitals, and academic medical centers are working with the CDC to track MRSA infections (CDC, NCEZID, DHQP, 2011). The CDC is committed to several short- and long-term “surveillance projects”

12. Biostatistics… • MRSA Case Patient Report Form: • http://www.cdc.gov/abcs/downloads/MRSA_case_rpt_form_2010.pdf • Forms are filled out for each MRSA patient at the healthcare facility and sent to the CDC. Forms include: • Description of patient (age, gender, ethnicity, race etc.) • Where treated • Was it Healthcare or community associated • Severity • Type/location of infection • Underlying factors,] • Predisposing factors • Outcome of the patient. (NCIRD, DBD, 2012).

13. Biomedical Factors • MRSA… • Caused by the bacteria Staphylococcus Aureus • Is a human pathogen • The pathogens contain toxins and virulence mechanisms • have altered PBP’s that antibiotics cannot attach to • Produce beta-lactams and lactamase • causes resistance to certain beta-lactams antibiotics. • methicillin, amoxicillin, penicillin, and oxacillin. • Hard to treat because of it’s resistance to antibiotics (Shopsin, Kreiswirth,2001) (Wang, Khan, Hines, Mediavilla, Zhang, Chen, Hoet, Bannerman, Pancholi, Robinson, Kreiswirth, Stevenson, 2012).

14. Biomedical Factors… • Community associated (CA) MRSA • Contain genes that are associated with skin and soft-tissue infections. • Panton-Valentine leucocidin (PVL) • Exfoliative toxin • Less resistance to methicillin • Hospital associated (HA) MRSA • larger resistanceto methicillin • associated with urinary tract, respiratory tract, and skin infections. (Giudice, Blanc, Durupt, F., Bes, M., Martinez, J.., Counillon, E., Etienne, 2006).

15. SOCIAL & Behavioral Factors: Ecological Model • The ecological model states that our social environment which includes intrapersonal, interpersonal, institutional, community, and public policy factors, all influence the behaviors we choose to partake in.

16. Behavioral factors that increase susceptibility: • Poor hygiene • (biting nails, leaving wounds untended and open etc.) • Participating in risky sexual behavior • Drug Use • Sharing of needles • Unsterile needles • Participate risky behaviors • Using public facilities • Participating in sports • Living in a crowded living situation (Cohen, Shuler, McAllister, Fosheim, Brown, Abercrombie, et al., 2007)

17. Ecological Model • Intrapersonal Factors: • Focuses on the individual and their knowledge and attitudes towards certain behaviors (Schneider, 2011). • We need to educate people about what MRSA is and what behaviors make them more susceptible so they are convinced to change their behaviors. • Interpersonal Factors: • Include peer pressure and family beliefs which influence a person’s behaviors and tendencies (Schneider, 2011). • Educate peer groups and family members in order for individuals to establish healthy beliefs, attitudes, behaviors, and tendencies. • Institutional factors: • Institutions must help educate employees and also set standards and enforce regulations in order to prevent the spread of MRSA within the communities. • Community: • Must educate the population all about MRSA and how to prevent it. Communities are largely responsible for providing education to the public. (Kreisel, K. M., Johnson, J., Stine, O., Shardell, M. D., Perencevich, E. N., Lesse, Roghmann, 2010).

18. Ecological Model: PUBLIC POLICY • Federal: • MRSA Prevention Collaborative works to address current MRSA issues • Affordable Care Act (ACA) funds states to help prevent healthcare-associated infections (HAI). • Require states to report HAI to the NHSN • CDC Prevention Epicenter works to prepare and inform states about how to prevent and treat HAI • Hand Hygiene Collaborative • NIOSH, HCSA and NORA are organizations that establish standards within hospitals, the workplace, and also environmental and community settings • (Department of Health and Human Services, 2009) • (CDC, NCEZID, DHQP, 2012).

19. PUBLIC policies continued • State • Have health departments in Emerging Infectious Diseases (EIP) • Enforce regulations set by the federal government within their state (like the Hand Hygiene Collaborative) • Report MRSA cases to NHSN • Local • Every community addresses MRSA differently • Awareness and educational programs are seen within schools, the workplace and other community facilities • Implement the federal and state regulations within their communities • Use the CDC as an educational tool • Work within institutions to promote healthy living and hygiene practices (Department of Health and Human Services, 2009) (CDC, NCEZID, DHQP, 2012)

20. References • Bo Shopsin and Barry N. Kreiswirth. (2001). Molecular Epidemiology of Methicillin-Resistant Staphylococcus aureus. Retrieved September 29, 2012 from: http://wwwnc.cdc.gov/eid/article/7/2/pdfs/70-0323.pdf. • Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) Division of Healthcare Quality Promotion (DHQP). (2012). State-based HAI prevention. Received from: http://www.cdc.gov/hai/state-based/index.html. • Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP). (2012). Methicillin-resistant Staphylococcus Aureus (MRSA) Infections.Retrieved September 15, 2012 from: http://www.cdc.gov/mrsa/. • Centers for Disease Control and Prevention, National Center for Emerging and ZoonoticInfectiousDiseases (NCEZID), Division of Healthcare Quality Promotion (DHQP). (2011). MRSA Statistics. Retrieved September 22, 2012 from: http://www.cdc.gov/mrsa/statistics/. • Cohen AL, Shuler C, McAllister S, Fosheim GE, Brown MG, Abercrombie D, et al. (2007). Methamphetamine use and methicillin-resistant Staphylococcus aureus skin infections.Received October 5, 2012 from: http://wwwnc.cdc.gov/eid/article/13/11/07-0148.htm. • Department of Health and Human Services. (2009).State of the Sector: Health Care and Social Assistance. Retrieved October 20, 2012 from: http://www.cdc.gov/niosh/docs/2009-138/pdfs/2009-138.pdf. • del Giudice, P. P., Blanc, V. V., Durupt, F. F., Bes, M. M., Martinez, J. P., Counillon, E. E., & ... Etienne, J. J. (2006). Emergence of two populations of methicillin-resistant Staphylococcus aureus with distinct epidemiological, clinical and biological features, isolated from patients with community-acquired skin infections. British Journal • Kreisel, K. M., Johnson, J., Stine, O., Shardell, M. D., Perencevich, E. N., Lesse, A. J., & ... Roghmann, M. (2010). Illicit Drug Use and Risk for USA300 Methicillin-Resistant Staphylococcus aureus Infections with Bacteremia. Emerging Infectious Diseases, 16(9), 1419-1427. doi:10.3201/eid1609.091802 • Schneider, Mary-Jane. (2011). Introduction to Public Health. (3rd Ed) Ontario, CA: Jones and Bartlett Publishers. • Shu-Hua Wang, Yosef Khan, Lisa Hines, José R. Mediavilla, Liangfen Zhang, Liang Chen, Armando Hoet, Tammy Bannerman, PreetiPancholi, D. Ashley Robinson, Barry N. Kreiswirth, and Kurt B. Stevenson. (2012). Methicillin-Resistant Staphylococcus aureusSequence Type 239-III, Ohio, USA, 2007–2009. Retrieved September 29, 2012 from: http://wwwnc.cdc.gov/eid/article/18/10/pdfs/12-0468.pdf.