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Running head: METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS Methicillin-Resistant Staphylococcus Aureus Mary Jacobs RN Ferris State University 1 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 2 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. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 3 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 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 4 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. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 5 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% METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 6 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 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 7 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). METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 8 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 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 9 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. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 10 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. Retrieved from http://s106175301.websitehome.co.uk/idrn_new/documents/events/workshops/CEP EDA1.pdf 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 infections in the United States. JAMA. 298 (15), 1763-1771. Retrieved from http://www.cdc.gov/ncidod/dhqp/pdf/a Centers for Disease Control and Prevention. (2010a). National MRSA education intiative: Preventing MRSA skin infections. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/mrsa/ Centers for Disease Control and Prevention. (2010b).Healthcare-associated Methicillin METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 11 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 aureus.Infection, Genetics and Evolution. 8, 747-763. doi:10.1016/j.meegid.2008.07.007 Enright, M., Feil, E., Grundmann, H., Randle, G., Robinson, A., & Spratt, B. (2002). The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA). National Academy of Sciences of the United Statesof America, 99(11), 7687-7692. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC124322/ 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 staph infections test identifies MRSA bacterium in two hours. United States Food and Drug Administration. Retrieved from http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm161552.htm Male, M.,Harper, A., Kroeger, J., Smith, T., & Tinkler, G. (2009) Methicillin-Resistant Staphylococcus aureus (MRSA) Strain ST398 Is Present in Midwestern U.S. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS Swine and Swine Workers. PLoS ONE 4(1): e4258. doi:10.1371/journal.pone.0004258 retrieved from http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0004258 Michigan Department of Community Health. (2010). Methicillin-resistant Staphylococcus Aureus (MRSA). Michigan Department of Community Health. Retrieved from http://www.michigan.gov/mdch/0,1607,7-132--178801--,00.html Michigan Department of Community Health. (2010). MRSA: What you should know. Michigan Department of Community Health. Retrieved from http://www.michigan.gov/documents/MRSA_brochure_FINAL_167898_7.pdf 12 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 13 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 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 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 14