Epidemiological Trends: MRSA Denise M. Korniewicz PhD. RN, FAAN Sr. Associate Dean University of Miami School of Nursing

1. Epidemiological Trends: MRSADenise M. Korniewicz PhD. RN, FAANSr. Associate DeanUniversity of Miami School of Nursing & Health Studies

2. Staphylococcus aureus Staphylococcus aureus: common cause of infection in the community Methicillin-resistant Staphylococcus aureus (MRSA): Increasingly important cause of healthcare-associated infections since 1970s In 1990s, emerged as cause of infection in the community

3. MRSA Strain Characteristics Were Initially Distinct

4. Outbreaks of MRSA in the Community Often first detected as clusters of abscesses or “spider bites” Various settings Sports participants Inmates in correctional facilities Military recruits Daycare attendees Native Americans / Alaskan Natives Men who have sex with men Tattoo recipients Hurricane evacuees in shelters

6. 2004/2005 ABCs MRSA Surveillance Areas Minnesota New York Oregon Connecticut California Maryland Colorado Tennessee Georgia Total Population: ~ 16.3 million

7. Black White Black White Incidence, Cases per 100,000 CA-MRSA Incidence Varies by Age and Race Atlanta, 2001-2002 Baltimore, 2002 26 per 100,000 18 per 100,000 Age Group (yr) Age Group (yr) • Fridkin et al NEJM 2005;352:1436-44

8. Most Invasive MRSA Infections Are Healthcare-Associated Healthcare-Associated Community-Associated 86% 14% Klevens et al JAMA 2007;298:1763-71

9. Incidence of Invasive CA-MRSA Infections and Deaths by AgeActive Bacterial Core surveillance (ABCS), 2005 Incidence per 100,000 persons Overall Incidence (all ages): Infections: 4.6 per 100,000 Deaths: 0.5 per 100,000 Klevens et al JAMA 2007;298:1763-71

10. MRSA Was the Most Commonly Identified Cause of Purulent Soft Tissue Infections Among Adult ED Patients (EMERGEncy ID Net), August 2004 59% (97% USA300) 54% 39% 15% 55% 74% 51% 68% 60% 60% 72% 67% Moran et al NEJM 2006;355:666-674

11. S. aureus Nasal ColonizationNational Health and Nutrition Examination Survey 2001-02 S. aureus: 32.4% = 89.4 M people MRSA: 0.8% = 2.3 M people MRSA colonization associated with age >= 60 years & being female

12. Emerging Multi-Drug Resistance in USA300? Clusters of USA300 isolates with multiple resistance to erythromycin, clindamycin, tetracycline, ciprofloxacin, and mupirocin1 Resistance to ≤ one class of antibiotics other than beta-lactams is still the most common resistance pattern in MRSA USA300 TMP/SMX resistance rare in MRSA USA300 1Diep et al Lancet 2006. Han et al J Clin Micro 2007.

13. Methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA) Among ICU Patients, 1995-2004 Source: National Nosocomial Infections Surveillance (NNIS) System

14. Vancomycin-resistant Enterococi Among ICU Patients, 1995-2004 Source: National Nosocomial Infections Surveillance (NNIS) System

15. 3rd generation cephalosporin-resistant Klebsiella pneumoniae Among ICU Patients,1995-2004 Source: National Nosocomial Infections Surveillance (NNIS) System

16. Fluoroquinolone-resistant Pseudomonas aeruginosa Among ICU Patients, 1995-2004 Source: National Nosocomial Infections Surveillance (NNIS) System

17. MRSA: Prevention Strategies focusing on increased awareness, early detection and appropriate management, enhanced hygiene, and maintenance of a clean environment have been successful in controlling clusters / outbreaks of infection.

18. The Pathophysiology of Methicillin Resistant Staph Aureus (CA-MRSA) Presented By: Diego Deleon MD

19. History • 1941 introduction of Penicillin G • Within 4 years, first case of penicillin resistant, Staph. Aureus, PRSA, discovered. • 1960 development of Methicillin to treat PRSA • 1961 MRSA appears • 1980s Resistant strains appeared against • Chloramphenicol • Tetracyclines • Macrolides

20. History cont 1996 long-predicted emergence of a strain with decreased susceptibility to Vancomycin

21. Staphylococcus Aureus • Most common etiologic agent of skin and soft tissue infection • Infection by susceptible agents is usually caused by endogenous flora • Strains of S. Aureus harbored in the nasal cavities or other sites of colonization

22. Infective Characteristics • Colonization • Nasopharynx • Skin • Infection can occur through intact or disrupted skin • Resistance to b-Lactam • Bacterial production b- Lactamase • mecA Gene- SCCmec group • Transpeptidase PBP2a

23. Genetic Characteristics • All MRSA are characterized by presence of: • mecA • Encodes for altered penicillin binding proteins (PBBs)(PBP2a) on their cell walls • Low affinity binding of anti-staph penicillins, results phenotypically to resistance to all beta lactam antibiotics.

24. PATHOPHYSIOLOGY • CA-MRSA- SCCmecIV & V • Panton-Valentine Leukodicin- Cytotoxin(up to 70% CA-MRSA Strains) • Increased virulence • Cause of necrotic skin lessions- on skin or mucosa • Necrotic hemorrhagic pneumonia

25. Pathophysiology cont • Initial Manifestation • Folliculitis/Soft tissue infection • Infected pimple or insect bite • Progression to abscess formation • Capable of progressing to life threatening sepsis • Clinical examination • Limited area of redness and tenderness • Warmth and swelling • Ocassionally joint pain

26. Pathophysiology • Opportunistic Invader • Invasive disease by breaching host defense barriers- due to disruption or dysfunction of such barriers • Skin conditions provide opportunity for colinization • Folliculitis- Infection of follicular ostia • Furuncle- Deep-seated necrotic infection of hair follicle • Carbuncle- Deep infection of a series of hair follicles • Paronychia- Infection of the lateral nail folds • Acute skin breaks • Puncture wounds • Abrasions/Lacerations

27. Pathophysiology cont. • Subsequent colonization of Nasopharynx • Respiratory tract infection • Infection after aspiration • Obstruction of repiratory tract • Tumor • Aspiration • Impairement mucociliary function • Chronic bronchitis • Acute viral infection

28. Pathophysiology cont. • Mechanical transmission • Intubation of the trachea • Provides a conduit through which the pathogen can reach the lower respiratory tract

29. MRSA Skin Infection

30. The Recognition, Diagnosis and Treatment of MRSA Jeanne H. Siegel PhD, ARNP Assistant Professor University of Miami School of Nursing and Health Studies

31. Who Gets “Staph” / MRSA?: • Anyone who come into contact with colonized individuals or contaminated surface, can contract the infection. • “Staph” and MRSA are spread either by direct physical contact or indirect touching of contaminated objects. • This includes touching, using, and/or sharing sheets, towels, clothes, equipment, dressings, personal items, bar soap, etc. which have been used by someone who has “staph” and/or MRSA, along with poor hygiene habits (e.g. hand washing, showering, etc.)

32. What Does “Staph” / MRSA Look Like? • Some can be red, swollen, painful, and/or have pus or other drainage. The pustules may be confused with insect bites initially, and may also be associated with existing abrasions. • Initially, it is very difficult to determine SA from MRSA

33. CA MRSA/ SAInitial Presentations • Most SA infections are skin infections, including: • boils (pus-filled infections of hair follicles), • abscesses (collections of pus in pockets under the skin), • styes (infection of glands in the eyelid), • carbuncles (infections larger than an abscess, usually with several openings to the skin), • cellulitis (infection of the skin and the fat and tissues that lie immediately beneath it), and  • impetigo (a skin infection that produces pus-filled blisters).

34. MRSA Presentations

39. Symptoms of a more serious staph infection may include: • Rash • Shortness of breath • Fever • Chills • Chest pain • Fatigue • Muscle aches • Malaise (general feeling of illness) • Headache Siegel JD, Rhinehart E, Jackson M, & Chiarello L (2006).

40. Screening and diagnosis • Doctors/Nurse Practitioners diagnose MRSA by checking a tissue sample, urine, or nasal secretions for signs of drug-resistant bacteria. • Newer tests that take 2-5 hours are improving detection and treatment of the bacteria. • In the hospital, you may be tested for MRSA if you show signs of infection or if you are transferred into a hospital from another healthcare setting where MRSA is known to be present. • You may also be tested if you have had a previous history of MRSA.

41. Risk Factors • Because hospital and community strains of MRSA generally occur in different settings, the risk factors for the two strains differ. • Risk factors for hospital-acquired (HA) MRSA include: • A current or recent hospitalization. • Residing in a long-term care facility. • Invasive devices. • Recent antibiotic use. • These are the main risk factors for community-acquired (CA) MRSA: • Young age. • Participating in contact sports. • Having a weakened immune system. • Living in crowded or unsanitary conditions. Outbreaks of CA-MRSA have occurred in military training camps and in American and European prisons. • Association with health care workers. People who are in close contact with health care workers are at increased risk of serious staph infections. Siegel JD, Rhinehart E, Jackson M, & Chiarello L (2006).

42. Treatment • Both hospital and community associated strains of MRSA still respond to certain medications. In hospitals and care facilities, doctors generally rely on the antibiotic vancomycin to treat resistant germs. CA-MRSA may be treated with vancomycin or other antibiotics that have proved effective against particular strains. • Although vancomycin saves lives, MRSA may grow resistant as well; some hospitals are already seeing outbreaks of vancomycin-resistant MRSA. To help reduce that threat, doctors may drain an abscess caused by MRSA rather than treat the infection with drugs. CDC, 2007

43. Complications of Failure to Treat • Possible Complications • Serious staph infections may lead to: • Cellulitis • Endocarditis • Toxic shock syndrome • Pneumonia • Blood poisoning • Organ failure and death may result from untreated MRSA infections. Siegel JD, Rhinehart E, Jackson M, & Chiarello L (2006).

44. MRSA in Children V.Padron Fajardo PhD, ARNP, FNP

45. Origin • Hospital Acquired • Recent hospitalization • Recent antibiotic therapy • Chronic disease • Surgery • ETs • Household contact with a carrier • Community Acquired • SA survives on inanimate objects >51 days • Cutaneous infections (skin-borne organisms) • Undetected colonization Pursell, 2003)

46. Differential Strains of MRSA • Community MRSA strains originating from acute setting • Community onset • Unique community strain • Community associated (community acquired) • Increase of 33% to 65% over 1 year • Not a multi-drug resistant strain • “Children with MRSA cutaneous infections were more likely to be healthy, whereas children with MSSA cutaneous infections were more likely to have traditional MRSA risk factors…. (Chen, et al., 2006)

47. Epidemiological Trend reinforces need for Anticipatory Guidance • INVESTIGATE • Vigilance • S/S • Break in skin integrity • Limited range of motion • Febrile illness • Errythema • Edema • Rash • Elevated WBCs with increase in neutrophils and bands • Culture

48. Anticipatory Guidance • Hand washing • S/S infection • Knowledge of risk factors • Avoid secondary infections

49. Prevention of “Staph” and/or MRSA: • Although treatable, there can be complications associated with “staph” and MRSA infections, making prevention the best measure to combat these infections. The Centers for Disease Control suggest the following measures for preventing staphylococcal skin infections, including MRSA: • Practice good hand hygiene by washing hands frequently and in a thorough fashion with soap and warm water or using an alcohol-based hand sanitizer. • Take a shower with hot water and wash with soap (liquid antibacterial soap, not bar soap) following all activities (e.g. strength & conditioning sessions, practices, and competitions). • Avoid sharing towels, equipment, razors, soap (use liquid soap instead of bar soap), etc. • Use a barrier (e.g. clothing or a towel) between your skin and shared equipment. • Wipe surfaces of equipment before and after use. • Clean and properly cover any open wounds such as turf burns, abrasions, lacerations, etc. with an appropriate bandage at all times. • Avoid whirlpools, hydrotherapy pools, cold tubs, swimming pools, and other common tubs if you have an open wound. • Maintain clean facilities and equipment. • Do not ignore skin infections, pimples, pustules, abscesses, etc. Report these to a physician/nurse practitioner immediately. CDC, 2007

50. Identifying MRSA Prevention/Strategies in the Acute Care Setting Presented by Mary E. Asher RN MSN CS CPAN