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Running head: METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS
Methicillin-Resistant Staphylococcus Aureus
Mary Jacobs RN
Ferris State University
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Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging infectious disease. It
continues to increase the numbers of patients and community members it is affecting.
Transmission of the bacteria is easily spread, but can easily be isolated and the spread
prevented. The problem lies with the presentation and identification of the bacteria, even
then treatment is not always easy due to its resistance to antibiotics. The development of
a vaccine is promising but yet still several years away. The best treatment is prevention
and including hospital personnel along with educating the public is the best prevention
available today.
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Methicillin-Resistant Staphylococcus aureus
Staphylococcus aureus was discovered in the 1880 (Deurenberg, & Stobberingh,
2008), and since then has grown adapted and changed with seven different variants type
one to V11, all made possible by the mecA gene which helps it to survive. In addition to
the variants of the genetic make-up, it presents itself into separate yet now merging,
environments-- community acquired MRSA (CA-MRSA) and hospital acquired MRSA
(HA-MRSA). Presently there are over 912 MRSA and methicillin-susceptible S. aureus
(MSSA) isolates (Enright et al, 2002). There is rapid advancement in the ability for this
bacteria to adapt and change, and a there is even more need for new antibiotics or
vaccines to be developed to prevent this bacteria from becoming a pandemic. So many
charts, an increasing number of hospital patient’s charts, seem to be flagged with
Methicillin Resistant Stapylococcus Aureus (MRSA). Is this truly an increase in numbers
or are hospitals becoming better at diagnosing it? Education on hand washing for hospital
staff, family, and patients needs to be increased, and the possibility of a vaccine to
prevent it is an exciting adjunct for treatment on the horizon. Combined education among
the public and hospital staff is key to the reduction and the advancement of MRSA.
MRSA’s Increasing Grip
The numbers of patients with MRSA is increasing not only within HA-MRSA, but
also CA-MRSA. It is on the rise, it keeps changing, it is difficult to treat, and it is killing
more people every year. The rapid rise from 1999 to 2005 alone shows how quickly
MRSA is climbing to the top of the disease tree (Appendix A). These things make it an
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emerging infectious disease, which is worth studying and finding cures or immunizations
to fight against it. These following studies have been done to help and disclose
information for the management of MRSA.
The chase study looks at new drug regimens to help combat against MRSA. Four
hundred eighty-nine MRSA blood isolates were tested over four time periods spanning
eleven years with the last one done in December 2006 (Chase, et al., 2009). Chase
reveled an emerging type of Stapylococcus aureus, called heteroresistance vancomycinintermediate S. aureaus (hVISA). “The first isolate of hVISA identified was reported
from Japan in 1997” (Chase, et al). The study introduces the impact of hVISA on patient
outcomes as increased, but still has to many variables to have a solid conclusion on its
affect, against previous MRSA variants, and needs to be looked at again.
In 2005 a study by Carey et al. (2007) showed out of 8987 cases of MRSA
observed, there were 1598 deaths, many variables did effect the out comes related to the
deaths but all were associated with MRSA infection. The Carey evaluation shows a high
death rate continues to make MRSA not only a deadly disease but also one, which needs
to remain on the emerging infectious disease list.
Ventilated patients in the ICU from 2001 through 2008 with MRSA were
evaluated, several key factors presented themselves: ICU’s have little in reserve to
control multi-drug resistance among gram-negative bacteria, treatment is limited,
treatment should be short, admission screening should be done and infection control ie
hand hygiene is crucial to prevent person to person spread (Carey, 2007). This study
gives insight into how MRSA spread can be stopped, by just the simple technique of
good hand washing.
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The Center for Disease Control and Prevention (CDC) posts these statistics for the
increase of MRSA from 1974 to 2005:
In 1974, MRSA infections accounted for two percent of the total number
of staphylococcus aureus infections; in 1995 it was 22%; in 2004 it was
63%. CDC estimated that 94,360 invasive MRSA infections occurred in
the United States in 2005; 18,650 of these were associated with death
(CDC, 2010b).
Transmission
Transmission can be from person to person, and zoolitic. Michigan Department of
Community Health (MDCH) gives basic information (2010) to describe MRSA, “it is
spread from person to person through hands or close, skin –to skin contact.” The MDCH
explains it can spread from infected wound drainage from one wound site to another and
to other persons. The most alarming information, and the most inflammatory is the fact it
is being spread from hospital patient, to hospital staff, and to a new host. MRSA is a
nosocomial infection or one which is hospital acquired by many patients. Any area,
which is enclosed and houses a large number of people, increases the risk of spreading
MRSA. Places like jail, dormitories, and military housing are good examples of places
where the infection could be easily transmitted. Those members of society most at risk
are immunosupressed patients, young and old patients, those living in close quarters, and
vent dependent patients especially in the intensive care unit.
Male (2009) did a pilot study, which showed colonization MRSA in workers taking
care of swine. The swine had 49% prevalence in MRSA and the workers had 45%
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colonization, showing MRSA was common among swine production systems in the
Midwestern U.S and could also become an important reservoir for this bacterium (Male
et al., 2009). This study again shows how adaptable MRSA is to so many unique
environments, which makes it so much scarier.
Isolation
Isolation of MRSA patients is recommended in certain situations, but not all. In fact
one specific study done on intensive care units, and isolation of MRSA positive patients
showed no specific decrease in the spread with the isolation of the patients (Bellingan et
al., 2005). Every patient, healthcare worker, and family member should practice good
hand hygiene to prevent the hand-to-hand spread of MRSA. If handling any secretions
from a MRSA patient a mask should be worn. Use of gloves and gowns is an effective
preventative measure. Standard and contact precautions should be observed for every
patient. The State of Michigan does not require disclosure of individual cases; only after
outbreaks of exposure meaning only after at least three cases in one community has been
identified with positive cultures (Michigan Department of Community Health, 2010).
Isolation for respiratory MRSA is at times necessary but rare.
Clinical Presentation
A staph infection or wound can look like almost any other insect bite or skin
infection, even the signs and symptoms of the infection can be similar to many other
infections like cellulitis, or an allergic reaction. Signs and symptoms of MRSA skin
infections are areas on the skin that may be red, swollen, painful, warm to the touch, full
of pus or other drainage, and accompanied by a fever (Centers for Disease Control and
Prevention, 2010a). Diagnosis is the key, then steps need to be taken to the quick
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initiation of treatment. If a wound is suspected of being MRSA it should be cultured so it
can be treated with the most effective antibiotic. MRSA does not always look the same,
view the multiple places and appearances it can have (Appendix B). The real risk is when
MRSA becomes a bacterimia, and invades the whole body, and then can quickly cause
death.
Diagnosis
Visually looking at wound is not the right way to diagnose MRSA, using cultures
and DNA testing is the most appropriate. The Food and Drug Administration (FDA)
released news of a new lab test, which can be used to diagnose MRSA (Food and Drug
Administration, 2008). This lab test identifies with 100% the MRSA-positive specimens
and more than 98% of the more common, less dangerous staph specimens, and it can be
done with in two hours (FDA). Still yet most diagnosis is being done by the routine
culture technique, which requires forty-eight hours for the bacteria to grow, on a Petri
dish, and then be read under a slide. Patients with a history of immunosuppressant, or
increased use of antibiotics should be looked at more closely than others due to their
increased risk of developing a MRSA infection.
Therapy
Prevention of MRSA is key prior to treatment. This is the idea behind Denmark’s
embark against MRSA, and after prevention failed, destruction was accomplished by
antibiotic treatment. One treatment for MRSA has been the “Search-and-Destroy”
technique used by Denmark which decreased its MRSA prevalence from 30% to 1%, this
was prior to the increase of CA-MRSA and may no longer be as effective (Deurenberg, &
Stobberingh, 2008).
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Treatment has traditionally been the use of vancomycin, but new studies are
showing even this antibiotic is not stopping MRSA. In 2004, Sakoulas et al, (Chang et, al,
2010) observed a significant risk for vancomycin treatment failure in MRSA bacteremia
and are first indicated by increasing vancomycin minimum inhibitory concentration
(MIC). Patients whom show a high vancomycin MIC, tend to have higher mortality rates,
this tends to apply to patients in the ICU who have been hospitalized for a long time
(Chang et al.). This shows the strength at which this bacteria is growing and changing.
New antibiotics are being developed. Etamycin has recently been evaluated for its ability
to inhibit MRSA but has not been found to kill CA-MRSA as effectively as vancomycin
(Fenical, et al, 2010). For basic MRSA infections vancomycin is still a good drug
regimen, yet all bactremias should still continue to be cultured and treated with the most
appropriate drug based on the culture results and susceptibility.
Prevention of MRSA is on the forefront with the study of a vaccine use possibility.
The vaccine may last only a year at present time and is most applicable to patients preoperatively, or in the setting of CA-MRSA situations like prior to incarceration (Bulens et
al., 2009). Even though the prospect of a vaccine is exciting and could be lifesaving it is
still about ten years away (Bulens et al.), theoretically the study does predict preventing
about 13,000 cases of invasive MRSA.
Conclusion
The health community is sorely lacking in its ability to treat MRSA, not for lack of
trying but because the bacteria keeps changing and adapting. Our ability to learn and
adapt cannot even come close to this bacteria’s ability to change. The need for new
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antibiotics other than vancomycin is clear. The need to develop a vaccine, which is
useable, is also clear, and yet taking ten years to do so seems almost reckless.
Recommendations for more allocated funds for the research and development for MRSA
is imperative for it is on the verge of becoming a pandemic.
MRSA continues to learn, adapt, grow and attack. As the public and the health care
community we should do the same. Education to the public needs to continue, to help
patients learn signs and symptoms of wounds, and to ask their physicians about poorly
healing wounds, so as to receive and obtain quick treatment and thus prevent further
spread of MRSA. Simple steps with in the hospital need to be initiated (not shaving
patients while in the hospital, having patients and staff be vigilant in hand washing).
There needs to be quick identification by staff employees of MRSA and MRSA
bacterium, with swift treatment with antibacterial course. The new and quicker
production of a vaccine, which could prevent the need to save lives with vancomycin,
needs to be developed.
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Reference
Bellingan, A., Cepeda, J., Cookson, B., Cooper, B.,Hayman, S., Hails, J., Jones, K.,
Kwaku, F., Kibbler, C., Shaw, S., Singer., M., Taylor, L., Whitehouse, T., &
Wilson, P. (2005). Isolation of patients in single rooms or cohorts to reduce spread
of MRSA in intensive-care units: prospective two-centre study. Articles. 365.
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Bulens, S., Dumyati, G., Fridkin, S., Gershman, K., Hageman, J., Harrison, L., Lucero,
C., Lynfield, R., Nadle, J., Petit, S., Ray, S., Schaffner., W., Townes, J., & Zell, R.
(2009). Evaluating the potential public health impact of a Staphylococcus aureus
vaccine through use of population-based surveillance for invasive methicillinresistant S. aureus disease in the United States. Vaccine, 27, 5061-5068.
Carey, R., Craig, A., Dumyati, G., Fosheim, G., Fridkin, S., Gershman, K., Harrison, L.,
Klevens, R., Lynfield, R., McDougal, L., Morrison, M., Nadle, J., Petit, S.,Ray, S.,
Townes, J., & Zell, E.(2007) Invasive Methicillin-Resistant Staphylococcus aureus
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Centers for Disease Control and Prevention. (2010a). National MRSA education intiative:
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Retrieved from http://www.cdc.gov/mrsa/
Centers for Disease Control and Prevention. (2010b).Healthcare-associated Methicillin
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Resistan Stapylococcus aureus (HA-MRSA). Centers for Disease Control and
Prevention. Retrieved from http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html
Chase, P., Johnson, L., Jose, J.,Khativ, R., Musta, A., Riederer, K., & Shemes, S. (2009).
Vancomycin MIC plus heteroresistance and Outcome of Methicillin-resistant
Staphylococcus aureus bacteria: Trends over 11 years. Journal of Clinical
Microbiology. 47(6) 1640-1644. doi:10.1128/JCM.02135-08
Deurenberg. R., Sobberingh, E. (2008). The Evolution of Staphylococcus
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Enright, M., Feil, E., Grundmann, H., Randle, G., Robinson, A., & Spratt, B. (2002). The
evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA).
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Fenical, W., Haste, N., Hensler, M., Jensen, P., Maloney, K., Nizet, V., Perera, V., &
Tran, D. (2010). Activity of the streptogramin antibiotic etamycin against
methicillin-resistant Staphylococcus aureus. The Journal of Antibiotics. 63, 219224. Doi:10.1038/ja.2010.22.
Food and Drug Administration. (2008). FDA clears first quick test for drug resistant
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Staphylococcus aureus (MRSA) Strain ST398 Is Present in Midwestern U.S.
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Swine and Swine Workers. PLoS ONE 4(1): e4258.
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Appendices
Appendix A
Klein. E., Laxminarayan, R., Smith, K. (2007). Hospitalizations and deaths caused by
methicillin-resistant Staphylococcus aureus, United States, 1999–2005. Emerging
Infectious Disease. Retrieved from
http://www.cdc.gov/EID/content/13/12/1840.htm
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Appendix B
Moore, M. (2010). MRSA Pictures and pictures of staph infection pictures. Staph
Infection Resources. Retrieved from http://www.staph-infectionresources.com/mrsa-pictures.html
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