RESOURCE CENTER

Unlocking the Mystery of MRSADebbie Sandlin, RN, CPAN

STAPHYLOCOCCUS AUREUS, often referredto as ‘‘staph,’’ is a type of bacteria carried onthe skin and in the nose of approximately33% of the population of all healthy people.Because you have this bacteria on yourbody does not mean that you are ill. If youhave staph on your skin or in your nosebut are not sick, you are said to be ‘‘colo-nized’’ but not infected with staph. Staphbacteria are usually harmless unless they en-ter the body through a cut or other wound;even then they often cause only minor skinproblems in healthy people.1 Older adultsor people who are ill or have weakened im-mune systems may suffer serious illnesswhen infected with staph.

In the late 1960s, hospitals began to see a strainof staph that was resistant to the broad-spectrum antibiotics commonly used to treatit.1 Strains of staph that have acquiredresistance to beta-lactam antibiotics such asoxacillin, penicillin, and amoxicillin are calledmethicillin-resistant Staphylococcus aureus,or MRSA. Antimicrobial resistance occurswhen bacteria change or adapt in a way thatallows them to survive in the presence of anti-biotics designed to kill them.2 MRSA, one ofthe first germs to outwit all but the most pow-erful drugs, is very dangerous and can belethal.1 Carriers of MRSA have the ability tospread it, even if they themselves are not sick.

Healthcare-Associated MRSA(HA-MRSA)

Staphylococcus aureus was first exposed topenicillin in hospitalized patients in the1940s and the bacteria almost immediatelybegan developing resistance.2 According tothe Centers for Disease Control and Preven-

Journal of PeriAnesthesia Nursing, Vol 23, No 2 (April), 2008: pp 137-139

tion (CDC), the first reported episode ofMRSA in the United States occurred in 1968.3

Healthcare-acquired MRSA (HA-MRSA) is oftenseen in surgical wound infections, bloodstream infections, and pneumonia. It can beseen in cellulitis, endocarditis, and toxic shocksyndrome. Untreated MRSA infections mayresult in organ failure and death.5 Patients athigh risk may have diabetes mellitus, organtransplantation history, intravenous drug usehistory, may be undergoing hemodialysis,may have AIDS, or be over 60 years old ora neonate. In 2005, about 94,360 people de-veloped a serious MRSA infection and 18,650died.2 The Association for Professionals inInfection Control estimated in a 2007 reportthat 1.2 million hospital patients are infectedwith MRSA each year in the United States,and that another 423,000 patients are colo-nized with it.1

Community-Associated MRSA

In the 1990s, a different type of aggressiveMRSA began showing up in the wider commu-nity known as community-associated MRSA orCA-MRSA. The genetic background of CA-MRSA is different from that of HA-MRSA. Thisstrain of MRSA is responsible for many seriousskin and soft tissue infections and pneumo-nia.1 It can cause severe infections and deathin otherwise healthy people outside of healthcare settings. CA-MRSA is seen in outpatientswith furuncles, large collections of pus that

Debbie Sandlin, RN, CPAN, is the Manager of Outpatient Sur-

gical Services at Southern Hills Medical Center, Nashville, TN.

Address correspondence to Debbie Sandlin, RN, CPAN;

e-mail address: debbie.sandlin@hcahealthcare.com.

� 2008 by American Society of PeriAnesthesia Nurses.

1089-9472/08/2302-0010$34.00/0

doi:10.1016/j.jopan.2008.01.007

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require drainage, that are often mistaken forspider bites. Skin infections often occur atsites of visible skin trauma, such as cuts andabrasions, and areas of the body covered byhair (back of the neck, groin, buttock,armpit, and the beard area of men). Ingrownhairs, known as folliculitis, can be infectedwith MRSA. This super-bug can also cause nec-rotizing fasciitis and necrotizing pneumonia.3

Persons at high risk may have a previoushistory of MRSA or close contact with some-one who does, may have a recurrent skindisease, crowded living conditions, history ofincarceration, participate in contact sports,use antibiotics frequently, abuse drugs, ormay be a child or young adult.

Leading Causes of AntibioticResistance

Leading causes of antibiotic resistance includeunnecessary antiobiotic use in humans, antibi-otics in food and water, and germ mutation.1

For many years, antibiotics were prescribedfor colds, flu, and other viral infections thatdo not respond to these drugs. In the UnitedStates, antibiotics can sometimes be found inbeef cattle, pigs, and chickens. The runofffrom feedlots enables these antibiotics tocontaminate streams and groundwater. Evenwhen antibiotics are used appropriately,they contribute to the increase of drug-resistant strains of bacteria because they can-not destroy every germ they target. Bacteriamutate much more quickly than new drugscan be developed.

Signs and Symptoms

Staph infections, including MRSA, generallypresent as a small red bump that may resemblea pimple, boil, or spider bite. These canquickly develop into deep painful abscessesand require surgical drainage. Sometimes thebacteria is confined to the skin, but it canalso cause life-threatening infections in bones,joints, surgical wounds, the bloodstream,heart valves, and lungs.1 Patients may have

painful lesions that are red, swollen, and feelwarm to the touch. Symptoms may includea rash, shortness of breath, fever, chills, chestpain, fatigue, muscle aches, malaise, andheadache.

Risk Factors

Risk factors for HA-MRSA include current orrecent hospitalization, residing in a long-termcare facility, and recent use of antibiotics.Bacteria can enter the body through invasivedevices such as dialysis catheters, urinary cath-eters, feeding tubes, endotracheal tubes, intra-venous catheters, triple lumen catheters, andimplanted ports. MRSA is a concern for hospi-tals because it can attack older adults and peo-ple with weakened immune systems, burnpatients, patients with surgical wounds, andthose with underlying health problems.MRSA is more prevalent in long-term carefacilities than in hospitals. Treatment withfluoroquinolones (ciprofloxacin, ofloxacin,or levofloxacin) or cephalosporin antibioticscan increase the risk of HA-MRSA.

Risk factors for CA-MRSA include young age,participating in contact sports, sharing towelsor athletic equipment, having a weakened im-mune system, living in crowded or unsanitaryconditions, and association with health careworkers. Young children can acquire CA-MRSA through a cut or scrape and may bemore susceptible because their immune sys-tems are not fully developed or they havenot yet built antibodies to common germs.Children and young adults also are more proneto the development of pneumonia. Bacteriaspread easily in contact sports through cutsand abrasions and skin-to-skin contact. It canalso be spread by sharing razors, towels, andathletic uniforms or equipment. MRSA hasbeen found to live in steam baths and steamrooms.4 People who have a weakenedimmune system from other disease processessuch as HIV/AIDS are more likely to have se-vere CA-MRSA infections. Living in crowdedor unsanitary conditions can be a cause, and

DEBBIE SANDLIN

UNLOCKING THE MYSTERY OF MRSA 139

outbreaks of CA-MRSA have occurred inmilitary training camps, schools, dormitories,military barracks, households, prisons, andpediatric and geriatric day care centers. Peoplewho are in close contact with health careworkers who have not washed their handsmay also be at higher risk.1

There are five factors, referred to as the ‘‘5 Cs,’’that make it easier for MRSA to be transmitted.They are Crowding, frequent skin-to-skinContact, Compromised skin (cuts or abra-sions), Contaminated items and surfaces, andlack of Cleanliness.

Table 1. Prevention Techniques

� Keep cuts, scrapes, or sores covered with a dry

bandage until they are healed

� Avoid contact with other people’s wounds or

bandages

� Wear gloves as appropriate and wash hands correctly

after removing

� Do not share razors, uniforms, towels, washcloths, or

athletic equipment with others

� Wash clothing and bedding that has been exposed to

drainage as usual and dry thoroughly in a clothes

dryer (The heat from the clothes dryer is beneficial)

� Tell any health care provider who treats you that you

have or have had in the past an MRSA infection

Diagnosis and Treatment

MRSA is diagnosed by taking a tissue samplefor culture of suspect drainage or by a nasalswab culture. Many simple skin infectionscan be treated by draining the abscess or boiland may not need antibiotic treatment.5

Serious MRSA infections may be treated withvancomycin (Vancocin, Vancoled), trimetho-prim-sulfamethoxazole (Bactrim, Bactrim DS,Septra, Septra DS), and linezolid (Zyvox).6 Itis important to finish all doses of antibioticsthat are prescribed because unfinished dosescan lead to the development of further drug re-sistance in the bacteria. Hospitalized patientsmay require supplemental oxygen and intrave-nous medication. In cases of kidney failure,dialysis may be necessary.

Prevention

The best way to prevent the spread of MRSA isto follow standard precautions and performthorough handwashing with soap and wateror an alcohol-based foam. Routine cleaning ofhorizontal surfaces, equipment, door knobs,and other areas commonly touched by handsshould be carried out. When working in a hos-pital, strict adherence to infection controlpractices should be enforced (Table 1).

References

1. Mayo Clinic. MRSA Infection. Available at: http://

www.mayoclinic.com/print/mrsa. Accessed December 18,

2007.

2. Centers for Disease Control and Prevention. MRSA:

Methicillin-resistant Staphylococcus aureus in the Healthcare

Setting. Available at: http://www.cdc.gov/Feature/MRSA.

Accessed December 25, 2007.

3. Coffman S. Bugs among us. Nursing Management online.

Available at: http://www.nursingmanagement.com. Accessed

October 25, 2007.

4. Centers for Disease Control and Prevention. Arctic

Investigation Program: MRSA. Available at: http://www.cdc.

gov/ncidod/aip/research/mrsa.html. Accessed October 25, 2007.

5. Centers for Disease Control and Prevention, National Insti-

tute for Occupational Safety and Health. MRSA and the Work-

place. Available at: http://www.cdc.gov/Features/MRSA/.

Accessed October 22, 2007.

6. MedlinePlus, Medical Encyclopedia. MRSA Infection.

Available at: http://www.nlm.nih.gov/medlineplus/ency/article/

007261.htm. Accessed October 25, 2007.