Community
Acquired MRSA
►
►
Julie Clark, RN and Mary Perez, RN Montgomery County Health
Department
April Aleman RN MUHSD
► Physiology
► Risk
of MRSA
factors
► Preventing
the Spread of MRSA
MRSA
Methacillin Resistant Staph Aureus
► Staphylococcus
aureus-a type of bacteria that
causes most skin and soft tissue infections
► Unable
to be killed by common antibiotics
including all penicillin (Methicillin) and
cephalosporins
► MRSA
has been reported in increasing numbers
among healthy persons of all ages. This is
referred to as Community Acquired MRSA
► Grows
rapidly and is difficult to kill
Results of infections
Patients infected with CA-MRSA most often
present with:
Skin or soft tissue infections- abscesses, boils,
cellulitis, and impetigo
Necrotizing fasciitis leading to disability
Bacteremia leading rapidly fatal septicemia
Endocarditis
Osteomyelitis
Toxic shock syndrome
Risk factors — Although many patients with CA-MRSA
infection have no risk factors,
THERE ARE SOME SPECIFIC RISK FACTORS:
► Skin
trauma (eg, "turf burns", lacerations or
abrasions)
► A higher body mass index
► Cosmetic body shaving
► Physical contact with a person who has a
draining lesion or is a carrier of MRSA
► Sharing equipment that is not cleaned or
laundered between users
Other studies have identified the following
significant risk factors:
► Prison residence
► Military personnel
► Comorbidities: Diabetes, Immunosuppressant illness
► Prior skin infection
► Illicit drug use
► Tattoo recipients
► Previous antibiotic use
► Owning a dog
WHAT SPORTS/ATHLETES ARE AT RISK?
ALL ATHLETES ARE AT RISK
Anyone participating in organized or recreational
sports is at risk
Even though little physical contact occurs in some
sports skin contact or activities that may lead to
spread of MRSA skin infections may take place
before or after participation such as in the locker
room.
ATHLETES WITH EXTRA RISK
► Lineman
or linebacker position in football
► Wrestling
► Rugby
► Football
► Swimmers who shave
► Basketball
Signs and Symptoms
Local swelling, redness, heat
► Painful lesion or pimple with or without drainage
► Boil-tender red lump with a white “head”
► Fever
► These skin infections commonly occur either at sites of
breaks in the skin such as cuts and abrasions, and areas
of the body covered by hair (for example, the back of the
neck, groin, buttock, armpit, or beard area of men).
►
MRSA infections start out as
small red bumps that can
quickly turn into deep, painful
abscesses.
BOIL
BOIL 2
CELLULITIS
CELLULITIS
TRANSMISSION
►Touching
skin, wounds of an
infected person
►Touching a dog
►Sharing towels
►Touching dirty athletic equipment
►Touching used bandages
MRSA Transmission
► S.
aureus is most often spread to others by
contaminated hands
Colonization vs: Infection
Colonization – state of a microorganism living in or
on a body without causing disease- even after
your infection is cleared up, and you don’t
experience any symptoms, you may still carry
MRSA.
ASSUME THAT
ALL
SURFACES
COULD HAVE
MRSA BACTERIA
AND
PRACTICE
PREVENTION!
PREVENTION Protect Yourself
► Practice
good personal hygiene
 Keep your hands clean by washing frequently
with soap and water or using an alcohol-based
hand rub.
►Liquid
soap is preferred over bar soap in
these settings to limit sharing.
►Wash
your hands after using shared weighttraining equipment
PREVENTION CONTINUED
►Shower immediately after exercise especially
after there has been substantial skin to skin
contact.
►Shower before using whirlpools
►Report possible infections to coach, athletic
trainer, school nurse, other healthcare providers, or
parents.
►Do not share bar soap and towels, razors ,
clothing
► Wear protective clothing or gear designed to prevent
skin abrasions or cuts
►Do not share ointments that are applied by placing your
hands into an open-container.
PREVENTION CONTINUED
► Use
a barrier between skin and shared equipment
e.g. exercise machines and massage tables
► Avoid contact with other people’s cuts and sores
► Wash cuts, scrapes, lesions, insect bites and sores
with soap and water
► Do not try to treat the infection yourself by picking
or popping the sore.
► Keep lesions clean and dry and cover them with
bandages until they are healed
► Change dressings when soiled or damp, place
dressings in a paper bag, then place in the regular
garbage
How should sports equipment be cleaned?
► Shared
equipment should be cleaned after each
use and allowed to dry, including mats etc.
 Wipe surfaces of equipment to disinfect before and
after use, especially if the surface has become wet with
sweat with an EPA registered agent
►Equipment, such as helmets and protective gear,
should be cleaned according to the equipment
manufacturers’ instructions to make sure the
cleaner will not harm the item.
►Wash uniforms and clothing after each use. Follow
the clothing label’s instructions for washing and
drying. Drying clothes completely in a dryer is
preferred.
How should athletic facilities be managed?
Athletic facilities such as locker rooms should always
be kept clean whether or not MRSA infections
have occurred among the athletes.
►Review cleaning procedures and schedules with
the janitorial/environmental service staff.
 Cleaning procedures should focus on commonly
touched surfaces and surfaces that come into
direct contact with people’s bare skin each day.
 Cleaning with detergent-based cleaners or
Environmental Protection Agency (EPA) registered detergents/disinfectants will remove
MRSA from surfaces.
Athletic facilities continued
►Non
approved cleaners and disinfectants,
including household chlorine bleach, can be
irritating and exposure to these chemicals
has been associated with health problems
such as asthma and skin and eye irritation.
►Take appropriate precautions described on
the product’s label instructions to reduce
exposure. Wearing personal protective
equipment such as gloves and eye protection
may be indicated.
Athletic facilities continued
►Environmental cleaners and disinfectants
should not be put onto to skin or wounds and
should never be used to treat infections.
►The EPA provides a list of registered products
that work against MRSA (List H):
http://epa.gov/oppad001/chemregindex.htm
►There is a lack of evidence that large-scale use
(e.g., spraying or fogging rooms or surfaces) of
disinfectants will prevent MRSA infections.
►Repair or dispose of equipment and furniture
with damaged surfaces that do not allow
surfaces to be adequately cleaned.
Should athletes with MRSA skin infections be
excluded from participation?
► If
sport-specific rules do not exist, in general,
athletes should be excluded if wounds cannot be
covered by a securely attached bandage that will
contain all drainage and will remain intact
throughout the activity.
► The athlete needs to told to practice good hygiene
measures
►.
► Top
Athletes with MRSA continued
►A
healthcare provider might exclude an athlete if
the activity poses a risk to the health of the
infected athlete (such as injury to the infected
area), even though the infection can be properly
covered.
► Athletes with active infections or open wounds
should not use whirlpools or therapy pools not
cleaned between athletes and other common-use
water facilities like swimming pools until infections
and wounds are healed
► Question:
Do we want to send home the
MRSA flyers to parents?
Preventing the Spread
► Carry
alcohol-based hand cleaner with you so you
can clean your hands if water and soap are not
available
Acknowledgement
►
Epidemiology and clinical manifestations of methicillin-resistant
Staphylococcus aureus infection in adults
John M Boyce, MDUpToDate (16.1)
►
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
October 2006 ~ Volume 22 ~ Number 221008
Community-Acquired Methicillin-Resistant Staphylococcus aureus (CAMRSA): An Update
► CA-MRSA Information for the Public, Centers for Disease Control and Prevention,
www.cdc.gov/ncidod
Diabetes Basics:
A Training
Program for
School Personnel
By April Roberts Aleman RN MS School Nurse
MUHSD Health Services Supervisor
Based on the program developed by
School Nurse Mary Zombeck RN MS CPNP
WHY IS IT IMPORTANT TO LEARN
ABOUT THIS ILLNESS?
.
► People
with this illness cannot utilize the food
they eat because they are not producing insulin.
► The illness can have deadly complications, both
short term and long term.
► The illness requires constant monitoring every
day of their life, it becomes oppressive.
Different Types of Diabetes
► Type
I diabetes, also known as Juvenile
Onset Diabetes, begins in childhood up until
about age 20.
► It is believed to be an autoimmune illness,
but not genetic.
► Patient is completely dependent on injected
insulin for survival.
Diabetes Type 2
► In
type 2 diabetes, either the body does not
produce enough insulin or the cells ignore
the insulin.
► Very
genetic
► High
incidence in certain ethnic groups
Prevention: Diet and Exercise
Acanthosis Nigricans
•TREATMENT
•Diet and exercise
•The next step, if necessary, is treatment with oral anti-diabetic drugs
.
Anti-diabetic drugs include:
Sulfonylureas metformin phenformin
rosiglitazone , pioglitazone, troglitazone.
acarbose miglitol. nateglinide, repaglinide exenatide
liraglutide (not FDA approved) sitagliptin pramlintide
•If necessary some type 2 diabetics need to use insulin.
•The long term effects are the same for diabetes type one:
Heart disease
•Heart attacks
•High Blood Pressure
Blindness (retinopathy),
Nerve damage (neuropathy)
Kidney damage
Gestational Diabetes
►
Gestational diabetes affects about 4% of all pregnant
women.
►
We don't know what causes gestational diabetes, but we
have some clues.
 The placenta supports the baby as it grows. Hormones from the
placenta help the baby develop.
 But these hormones also block the action of the mother's insulin in
her body. This problem is called insulin resistance.
 Insulin resistance makes it hard for the mother's body to use
insulin. She may need up to three times as much insulin.
Diagnosis
The Classic Symptoms
They are all due to high blood sugar which because the illness
is not diagnosed goes untreated until a crisis.










Polyphagia (frequently hungry)
Blurred vision
Polyuria (frequently urinating)
Fatigue
Polydipsia (frequently thirsty)
Weight loss
Poor wound healing (cuts, scrapes, etc.)
Dry mouth
Dry or itchy skin
Recurrent infections such as vaginal yeast infections,
groin rash, or external ear infections (swimmers ear)
Why is it important to take
care of diabetes???
The long term effects for diabetes type I:
► Heart disease
►Heart
attacks
►High Blood Pressure
►
►
►
Blindness (retinopathy),
Nerve damage (neuropathy)
Kidney damage
BALANCING ACT ALL THE TIME
INSULIN
► Insulin
is a naturally occurring hormone
that moves the glucose
from the blood stream to the cells, so the
body can use the glucose to work.
► The
pancreas makes insulin as the body
needs it, depending what a person eats
and how much they exercise.
►
►
►
►
►
TOO LITTLE INSULIN
Results in too much sugar in the blood
Thirst as body tires to dilute blood
Increased urination
Sleepiness
TOO MUCH INSULIN
Takes too much sugar out of the blood
Not enough sugar in the blood
for the brain to work.
Brain will die, life will cease.
Up until
Sept 2007
the standard
policy in
schools was
as stated
here.
Lawsuit against C.D.E.
► Good
settlement results regarding discrimination
and lack of care for diabetic students.
► EXCEPT The settlement allows an unlicensed
school employee to be trained and to administer
insulin.
► It is believed that this practice is against the Nurse
Practice Act and dangerous: school nurses are
refusing to teach UAPs to give insulin.
► The issue still needs to be settled.
► The diabetes association of America is upset
because there are not enough school nurses to
help children.
FOOD
►Food
provides the body with
glucose.
► The
brain can only use a sugar called
glucose to work. Without glucose the
brain will DIE in a matter of minutes!
Too much or too little FOOD
TOO LITTLE FOOD
► Too little food causes low blood sugar
► The blood sugar will be even lower if insulin is taken.
TOO MUCH FOOD
Too much food causes the diabetic to gain weight
The diabetic will need more insulin the more he eats
If he does not take enough insulin,
the blood sugar will be high
If the blood sugar gets too high this causes
hyperglycemia and this causes long term effects
► Starch
15 CARBS
► Vegetable 5
► Fruit 15
► Fat 0
► Meat 0
► Milk 12
Breads, Pastas, Beans, Chips, Potatoes
Is good for every student body!!!
Increasing Exercise:
Uses glucose (sugar)
Causes the level of sugar in the
blood to go down (low blood sugar)
Decreasing Exercise

Does not use glucose/sugar

If the diabetic does not eat
less the sugar will get too
high in the blood.

If the sugar is high in the blood
and the diabetic uses insulin to
lower it they will gain weight.

Encourage the diabetic to exercise
and maintain correct blood sugars.
Is good for diabetics, but they must
plan ahead and have snacks handy in
case their blood sugar gets too low.
May have to schedule PE at a time
convenient for the diabetic in terms of
blood sugar stability.
There are
3 variables
that influence
blood sugar
beyond the triangle.
BALANCING ACT ALL THE TIME
►
Stress causes the blood sugar to go up. Tests, boyfriend
issues, drama, girlfriend problems, home dysfunctions,
bad grades, up-coming tests, no money, yelling teachers,
out of control diabetes; it all can cause the diabetic
student to have a high level of glucose in their blood.
►
In general illness and injuries cause blood sugar to go
up, unless the diabetic stops eating (or is vomiting).
Signs of low blood sugar
MOST IMPORTANT PART OF THIS TRAINING
Mild hypoglycemia
► Symptoms of mild low blood sugar usually
develop when blood sugar falls below 60 to 65
mg/dL
► Nausea.
► Extreme hunger.
► Feeling nervous or jittery.
► Cold, clammy, wet skin; excessive sweating not
caused by exercise.
► A rapid heartbeat (tachycardia).
► Numbness or tingling of the fingertips or lips.
► Trembling.
Moderate hypoglycemia
►
MOST IMPORTANT PART OF THIS TRAINING
► If
blood sugar continues to fall, the nervous
system will be affected.
► Mood changes, such as irritability, anxiety,
restlessness, or anger.
► Confusion, difficulty in thinking, or inability to
concentrate.
► Blurred vision, dizziness, or headache.
► Weakness, lack of energy.
► Poor coordination.
► Difficulty walking or talking, such as staggering or
slurred speech.
► Fatigue, lethargy, or drowsiness.
Severe hypoglycemia
► The
symptoms of severe low blood sugar
develop when blood sugar falls below 30 mg/dL
and may include:
► Seizures or convulsions.
► Loss of consciousness, coma.
► Low body temperature (hypothermia).
► Prolonged severe hypoglycemia can cause
irreversible brain damage and heart problems,
► If emergency medical treatment is not provided,
severe hypoglycemia can be fatal.
Denial and Hypoglycemic
Unawareness
► Tighter
diabetic control is achieved through
intensive insulin therapy; however, an unwanted
consequence of this therapy is a threefold
increase in severe episodes of hypoglycemia
► Developmentally, children may also lack the
cognitive and emotional sophistication to
develop adaptive coping strategies in the face of
threatening experiences related to
hypoglycemia.
Treatment for hypoglycemia
► Food-Carbohydrates,
complex
►Juice
►Chips
►Fruit
►Bagels,
► Glucose
etc
Tabs
► Gucose Gel
► Glucagon
simple then
Glucagon Procedure
Essential Steps
►
►
►
►
►
►
►
►
►
Verify signs of severe low blood glucose:
Unable to swallow; Uncooperative; Combative; Unconscious.
Place student on side – or – in upright position if restless/uncooperative
Have someone call paramedics, parent, and school nurse
Place one of the following in cheek pouch closest to ground and massage:
15 gm. of Glucose Gel
If student becomes unconscious or starts to seize, give Glucagon
Perform first aid for seizure
When student is able to swallow give sips of regular soda pop (not diet) as
tolerated until paramedics arrive.
When paramedics arrive, student will be transported for medical care.
Document in aeries
HYPERGLYCEMIA
High Blood Sugar
►
Excessive thirst
►
Fatigue, weakness
►
Increase in number of trips to the bathroom
►
Blurry vision
►
Diabetic ketoacidosis
HYPERGLYCEMIA
Treatment
► Water,
LOTS
► Exercise
► Insulin
► Re
test after 20 to 30 minutes, if stable
return to class
MUHSD
Standard Accommodations
► Students
can check their blood sugar
anywhere on campus including in class
► Students can eat and drink in class
► Students can go to the restroom as needed
► Students can use the health office as
needed.
CONCLUSION
Together we can help the diabetic student
take good care of themselves,
attend school,
participate in student activities,
and enjoy life.