Much has changed since the common Staphylococcus aureus bacteria became resistant to many of the antibiotics that were available to treat it, leading to its name as methicillin-resistant Staphylococcus aureus (MRSA). What was once thought to be a hospital-based problem is becoming a major public health concern that providers should be aware of as they conduct patient assessments and avoid the risks of infection themselves.
The medical community first learned that this organism had developed resistance in Europe in the 1960s. The first U.S. cases were noted in the 1970s. From the '70s through the '90s, this resistant strain of bacteria appeared to be limited to the hospital and long-term care facility environmentƒwith about 60% of MRSA cases being diagnosed in ICUs.
But in 2000 it was noted that 73% of MRSA cases were being diagnosed in communities across the country. This is termed community-acquired MRSA or CA-MRSA. By 2004, 89% of MRSA cases were community acquired.
Community outbreaks have occurred in athletes in close-contact sports, IV drug users, inmates, group-home residents, and in health clubs/gyms. Cases acquired in tattoo establishments in Ohio, Vermont and Kentucky were also recently reported by the Centers for Disease Control and Prevention (CDC).
The primary mode of transmission is via open-skin-to-open-skin contact and open-skin contact with contaminated surfaces. In January 2007, a Columbia University study clearly documented cases of transmission of MRSA via sexual contact.1 Several previous reports had documented CA-MRSA among sports teams, military recruits, children in daycare centers and HIV-positive gay men, but no cases of sexual transmission of this infection.
The study was conducted from 2004Ï2006 in New York City and involved 114 people with positive cultures for MRSA. Nasal cultures and genital cultures were taken and cultured for Staphylococcus aureus. Researchers found three cases of heterosexual transmission of CA-MRSA. In each case, sexual partners reported a history of recurrent CA-MRSA infection in the pubic, vaginal or perineal region.
Two of the three study cases noted that pubic shaving was a practice, echoing findings of another study presented at the 2006 AIDS Conference that noted pubic shaving was associated with CA-MRSA in gay men.2 Further, the Columbia authors state that their work suggests colonization of the genital area and heterosexual activity among members from an infected household may lead to recurrent infection within the household and that households may become a reservoir for infection. The CDC has stated that this research appears to be on target.
CA-MRSA can also be transferred to surfaces by hands or bare skin contact, which is often the source of outbreaks among athletic teams. Transmission has been documented in close-living conditions as well.
CA-MRSA is increasingly common within communities, so it shouldn't be surprising that EMS providers are also being diagnosed with this now-common skin bacteria. Infection presents first as small red bumps, sometimes called ˙spider bites,Ó which then become deep, painful abscesses, or cellulitis. Diagnosis is made by culturing the drainage from the area. Treatment includes several antibiotics, such as vancomycin, Synercid and Tygacil.
Several departments have reported cases of MRSA infections and sought counsel on what should be done when an employee is infected. First, an MRSA infection should be considered confidential medical information and limited to the individual within the department responsible for reporting illnesses .
Second, establish that the employee is being treated. Further, every department should have measures in place to prevent infection in the workplace (see sidebar). The onset of this infection, in most cases, may not be patient-care related. By following these essentials, you can better protect yourself and your patients.
KEYS TO PREVENTION
Caused by MRSA, this cutaneous abscess on the hip of a prison inmate spontaneously drained, releasing its purulent contents.
Comply with the CDC/OSHA statement that health-care workers with open areas of the skin are to have those areas covered with a bandage. If the area is too large to cover with a bandage, then the health-care worker should not perform patient-care tasks;
- Wash your hands after glove removal and after touching contaminated objects/surfaces;
- Don't share personal protective equipment, body armor or structural firefighting gloves/clothing;
- Don't share towels or hygiene products;
- Use a barrier (towel or layer of clothing) between skin and shared exercise equipment;
- Clean exercise equipment and mats (with bleach/water at 1:100 dilution);
- Launder clothing as usual. No special requirements are needed for contaminated laundry; and
Educate and train all staff on MRSA and prevention measures.
(Sources: ˙Los Angeles County Department of Public Health guidelines for reducing the spread of Staph/CAMRSA in non-healthcare settings.Ó September 2004.www.lapublichealth.org. Wisconsin Antibiotic Resistance Network: ˙Community-associated MRSA information for the public.Ówww.warnwisconsin.org.)
ABOUT THE AUTHOR
Katherine West, BSN, MEd, CIC, is an infection control consultant with Infection Control/Emerging Concepts Inc and aJEMS editorial board member.