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Mercy! MRSA! Gail R. Hansen, DVM, MPH State Epidemiologist Kansas Department of Health and Environment Healthy Kansans living in safe and sustainable environments. Before starting, Thanks! Dr. Dan Hinthorn, KUMC Ms. Sheri Anderson, KDHE Healthy Kansans living in safe and sustainable environments. Staphylococcus aureus Gram positive cluster forming cocci Sources • • • Commonly carried on the skin and mucus membranes of humans Most common cause of skin infections in US A word about pets Healthy Kansans living in safe and sustainable environments. Diseases Topical • • • • Cellulitis Boils Impetigo Wound infections Antimicrobials may not be necessary for treatment Systemic • • • Bacteremia Endocarditis Toxic Shock Syndrome Require antibiotics Healthy Kansans living in safe and sustainable environments. What is MRSA? Methicillin-Resistant Staphylococcus aureus Resistant to other beta (ß) lactamaseresistant penicillins and cephalosporins Healthy Kansans living in safe and sustainable environments. Staphylococcus aureus perspective Staphylococcus has been around as long as history • • • • Egyptian mummies 1880s--usual cause of pus from wounds Sulfa drugs reduced infections but resistance developed Penicillins reduced infections but resistance developed Staph has virulence factors & defense mechanisms that cause rapidly progressive diseases, even with normal immune systems Healthy Kansans living in safe and sustainable environments. Resistance Staph have 1 of 5 Staph Cassette Chromosomes that hold resistance factors • SCC IV and V are small CA-MRSA, type IV. • SCC I-III are large HA-MRSA types I, II, or III • The SCCmec A IV (resistance gene to methicillin) can’t hold all types of resistances due to size First described in S. epidermidis in the 1970s Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Emergence of Antimicrobial Resistance Susceptible Bacteria Resistant Bacteria Resistance Gene Transfer New Resistant Bacteria Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Selection for antimicrobial-resistant Strains Resistant Strains Rare Antimicrobial Exposure Resistant Strains Dominant Healthy Kansans living in safe and sustainable environments. Staph has out-smarted us at every turn Able to make cell walls even though methicillin should prevent that Mortality was 70% before penicillin in 1937 • 1944, with penicillin--mortality 28% • 1954, with b-lactamase--mortality 50% • 1962, with methicillin--mortality 30% S. aureus is the #1 pathogen in children Evolution of Antimicrobial Resistance Penicillin Methicillin Penicillin-resistant Methicillin-resistant S. aureus (1950s) S. aureus S. aureus (MRSA) (1960s) Vancomycin (1997) (2002) Vancomycin intermediate resistant S. aureus Healthy Kansans living in safe and sustainable environments. PVL and severe disease The PVL gene (Panton Valentine Leukocidin) • First described in 1894 • Further described by P&L in 1932 • It codes for a cytotoxin against WBC & RBC • PVL gene is not linked to SCCmec type IV Found in MSSA and MSSA with PVL Predated CA-MRSA. Healthy Kansans living in safe and sustainable environments. Toxins in staph S. aureus may have 30 extracellular products. • Enzymes, cytotoxins, hemolysins etc • Acts on cell membranes, forms a pore PVL, synergohymenotropic toxin Leukocytolytic & causes severe tissue damage Induces granule secretion, release of leukotriene B4, and IL- 8 from WBC. May cause necrotic skin and lung damage, any age SCCmecA typeIV Grows faster 5X more lethal than CA-MRSA without PVL Healthy Kansans living in safe and sustainable environments. Confusing names made easy Names are by PFGE, not phage type, ~80/81 • CA-MRSA are called USA-300, USA-500, USA1000, USA-1100. Most resistant to erythromycin, some clinda resistance. Most quinolone resistant and 25% resistant to tetras. • HA-MRSA are called USA-100 USA-200. Most resistant to erythromycin, clindamycin, quinolones. Most susceptible to tetra and trimethsulfa. Healthy Kansans living in safe and sustainable environments. HA-MRSA Scottish study • Increased new ICU cases of MRSA related to Nursing staff deficits Failure to use basic infection control practices Deficiency of environmental hygiene 160 sites cultured Sinks, curtains, bedrails, computers 23% were positive 70% were positive from site where hand contamination occurred. Organisms usually viewed as environmentally spread VRE, vancomycin resistant enterococci CDAD, Cl. difficile associated diarrhea Healthy Kansans living in safe and sustainable environments. HA-MRSA Transmission Person to person contact most important • Hands of staff, transiently colonized Environment plays a limited role • Equipment, surfaces Droplet-borne transmission is even less common Healthy Kansans living in safe and sustainable environments. Factors that Favor HA-MRSA Transmission High resident to staff ratios Lack of attention to basic infection control measures Use of common equipment without disinfection Personal item sharing among residents Limited facilities for handwashing Inappropriate use of antimicrobials Healthy Kansans living in safe and sustainable environments. HA-MRSA Prevention Hand hygiene • Antiseptic washing • Soap and water • Waterless handrubs/alcohol 70% better than 95% Not for visible dirt • Fake nails Beware donor fabrics Healthy Kansans living in safe and sustainable environments. CA-MRSA MRSA of persons who have not been hospitalized in the past year Usually skin infections in otherwise healthy people Virulence factors allow CA-MRSA to spread more easily or cause more skin disease 25-30% of population colonized with S. aureus • 1% (?) with MRSA Healthy Kansans living in safe and sustainable environments. CA-MRSA Transmission Mostly via contaminated hands • Contact with infected individuals • Contact with contaminated environmental surfaces Other risk factors • Skin-to-skin contact • Crowded conditions • Poor hygiene Environmental contamination • Not common Healthy Kansans living in safe and sustainable environments. The growth of CA-MRSA MRSA reported 2 yr after methicillin was first used (1961) • Predecessor to the USA300 strain • • • • Aborigines in Australia, New Zealand Native American children in MN, NE, ND MSM in LA, ATL, Boston Prisoners, athletes, wrestlers, football, fencers MRSA infections started in community 1980’s Majority of SSSI in ED across US now have CA MRSA most CA-MRSA appear to be resistant to β-lactams only Healthy Kansans living in safe and sustainable environments. CA-MRSA Syndromes Necrotizing skin infections (spider bites) Necrotizing fasciitis (“flesh eating” like strep) • Pyomyositis with eos in Africa, & pyomyositis in HIV. Septic thrombophlebitis of extremities Pelvic syndromes especially in children • • • • Septic arthritis of hips Pelvic osteomyelitis Pelvic abscesses Septic thrombophlebitis Waterhouse-Friderichson syndrome Rapidly progressive necrotizing pneumonia • Develops in hours, even in previously health young people. Healthy Kansans living in safe and sustainable environments. CA-MRSA Prevention Cover draining infections • HCW off work until open wounds healed. Wash hands • during day • after toileting • before eating Don’t share personal items Healthy Kansans living in safe and sustainable environments. CA-MRSA Prevention Wash linens in hot water Dry clothes in hot dryer, not air drying Shower after group sports, gym use, sauna, steam room or tanning • With draining wounds, no athletic competition • Clean communal surfaces at gym Immunization so far not effective Healthy Kansans living in safe and sustainable environments. Spider bite or MRSA? Start with an itch, then painful Get worse and not better with local treatment Both have central necrosis • Look blackish or dark red or purple in center Surrounding induration and erythema Slow to resolve • Neither Keflex nor Dapsone work Did you see the spider? Photo courtesy of Dr. D. Hinthorn, KUMC Healthy Kansans living in safe and sustainable environments. Treatment for MRSA Incise and drain abscesses Culture, culture, culture! • Results of susceptibility determine antimicrobials • Vancomycin Antimicrobials VRSA and VISA • • • • Trimeth-sulfa Doxy or minocycline Clindamycin Quinolones? No Healthy Kansans living in safe and sustainable environments. Surveillance Communication between facilities about MRSA + patients Review culture and susceptibility data Maintain confidential line listing of MRSA + patients Flag MRSA+patients to assist with precautions Active surveillance cultures for MRSA? • • • Not be a routine measure Maybe during an outbreak Routine culture and treatment in hospitals not effective in reducing MRSA Healthy Kansans living in safe and sustainable environments. Reporting Requirements Single cases of MRSA are not reportable in KS or MO Outbreaks are reportable in KS and MO Other states different • VRSA or VISA reportable from any site • MRSA reportable if isolated from sterile site • S. aureus reportable if it results in a serious infection • • resulting in death or admission to ICU MRSA labs reportable only All MRSA infection reportable Healthy Kansans living in safe and sustainable environments. MRSA Outbreaks 2 or more patients with MRSA infection that are epidemiologically linked • Roommates in LTC, cared for by the same • staff 2 members of the football team Infections have temporal relationship Call KDHE-OSE at 877-427-7317 • Report outbreak or request assistance Questions? ? ? 877-427-7317