MRSA, Cellulitis, UTI
Susan Fowler
sfowler@tricountycc.edu
Exemplars
• MRSA, Cellulitis, and UTI are
representative of the infection concept
for this semester.
• The infection concept will be carried
throughout this program with different
exemplars each semester. Each
semester the exemplars will be a little
more challenging.
MRSA—Methicillin-resistant
Staphylococcus aureus
• One of the most troublesome resistant
bacteria in the country.
• MRSA is resistant to all medicines in the betalactamase family that include all penicillins,
cephalosporins (Ancef, Keflex), and
carbapenems (Doribax, Invanz), as well as
other antibiotics such as erythromicin.
• Hospital-associated MRSA is more resistant
than community-associated.
Pathology of Resistance
• Resistance occurs when pathogens
change in ways that decrease the ability
of a drug or family of drugs to treat
disease.
• Bacteria are highly adaptable and have
evolved to the point that their genetic
and chemical makeup has changed.
Pathology of Resistance
• The antibiotics have lost their
effectiveness because the DNA and cell
walls of the bacteria have changed and
the antibiotic can no longer penetrate
the cell wall.
• Also, some bacteria now produce
enzymes that destroy or inactivate
antibiotics.
Contributory Practices to Resistance
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Giving antibiotics for viral infections
Prescribing unnecessary antibiotics
Inadequate drug regimens to tx cases
Using broad-spectrum antibiotics when
specificity would be better
• Pts who don’t finish their course of tx
• Pt lack of $ or other psychosocial issues
MRSA’s Importance
• Pathogenicity—very virulent; frequently
cause bloodstream and catheter
infections in hospitalized pts and skin
and respiratory infections in community
• Limited treatment options—Vancomycin
• Transmissible—colonized health care
workers; close contact in community
Risk Factors
• Repeated contact with health care
system
• Severity of illness
• Previous exposure to antimicrobials
• Underlying conditions
• Invasive procedures
• Previous colonization
• Advanced age
Modes of Transmission
• Main mode is via contaminated hands
from:
– colonized or infected patients
– colonized or infected staff
– contaminated articles or surfaces
Clinical Manifestations—HA-MRSA
• Colonized patients and workers have no
symptoms.
• S&S from persons infected with MRSA
are no different from S&S from other
infections.
• Definitive dx is from a culture.
Clinical Manifestations—CA MRSA
• Purulent lesion with a central head that
has a yellow or white center and may
be draining.
• Pts sometimes complain about a “spider
bite.”
• May have a fever
Recommendations
• Standard Precautions, specifically
handwashing guidelines (see BB)
• Transmission Based Precautions,
specifically Contact Precautions (BB).
– Donning gown and gloves upon entry to
the room for all interactions involving
contact with patient or areas in the
patient’s environment. Gown and gloves
should be discarded before exiting.
Additional Precautions
• Private room is preferred.
• Semi-private with another similar
patient who does not have another
infection or with patient who has no risk
factors.
• Allow socialization as long as wounds
are covered, body fluids are contained,
and handwashing is observed.
Prevention and the Nurse
• Wash hands before and after patient
contact.
• Wear PPE as directed by the infection
control team and dispose of
contaminated articles in a manner that
prevents spread.
• Make sure visitors are protected.
• Be aware of own health.
Treatment
• Vancomycin and two newer agents,
linezolid and daptomycin, are usually
used to treat HA-MRSA. Isolation
precautions are implemented.
• CA-MRSA is usually treated by draining
and culturing the skin lesion and giving
clindamycin or doxycycline.
Nursing Care and Education
• Administer antibiotic tx.
• Follow infection control guidelines and teach
visitors the guidelines.
• Teach those in the community:
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Wash or use hand sanitizer
Keep cuts and lesions covered
Don’t touch other peoples cuts or lesions
Do not share personal items like towels or razors
Cellulitis
• Inflammation and infection of
subcutaneous tissues—bacterial gain
access thru a break in skin
• Staphylococcus aureus and streptococci
are usual causative agents
• Most commonly found in feet or legs
• Complicated by poor perfusion
Other Types
• Erysipelas—cellulitis of the face
• Postseptal—involves the eye
• Eosinophilic—red or violet circular or
oval patches on the skin that are firm,
swollen, and itchy caused from too may
eosinophils in the blood.
• Please remember that the nursing
mgmt is not impacted by the types.
Etiology (Cause)
• Primary infection from trauma (sharp
objects, burns)
• Secondary infection from scratching
– Insect bites
– Impetigo
Complication of leg ulcers in people
with diabetes or peripheral vascular
disease
Risk Factors
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Diabetes
Immunosuppression
Peripheral Vascular Disease (PVD)
Lymphedema
Malnutrition
Clinical Manifestations
• Localized:
– Hot, tender, erythematous, and edematous area
with diffuse borders
– Deep tissue inflammation caused by enzymes
produced by bacteria and inflammatory response
– Edema sometimes severe and can cause skin to
crack and weep.
• Systemic:
– Chills, malaise, fever, elevated WBC
Treatment
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Moist heat
Immobilization
Elevation
Systemic antibiotic therapy—usually
with a penicillin derivative or cousin
• Hospitalization may be necessary
• Surgery may be necessary for
debridement and to R/O fasciitis
Complications
• Progression of inflammation and
infection can lead to:
– Necrotizing fasciitis (“flesh-eating”)
– Gangrene (death of tissue)—skin turns
black; purulent drainage present; foul odor
– Amputation
– Sepsis
Nursing Care
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Assess area and record—outline area
Check for blood culture order
Administer meds for infection and pain
Wound care as ordered
Consider effects of immobility and practice
prevention techniques
• Assist with mobility when pt can be OOB
• Address fears and concerns
• Evaluate effectiveness of care
UTI
• A.K.A. urinary tract infection
• Inflammation occurs concurrently with
infection altho can occur without
infection
• Women are at greatest risk
• 80% caused by Escherichia coli from
cross-contamination from the rectum.
Classifications
• Upper—kidney (pyelonephritis)
• Lower—bladder (cystitis) and urethra
(urethritis)
• Initial—first or isolated
• Recurrent—after first was resolved, new one
occurs
• Unresolved and persistent—continue even
after antibiotic tx
• Urosepsis—bloodstream infection from UT
Risk Factors
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Female
Pregnancy
Structural abnormalities
Foreign bodies (stones, catheters, dx
instruments)
Obstruction (tumors, strictures)—causes
urinary stasis
Impaired immunity (age, disease)
Multiple sex partners
Poor personal hygiene
Contributory Medical Practices
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Poor handwashing practices
Use of urinary catheters
Poor technique in inserting catheters
Poor catheter care
Poor perineal care
Use of diagnostic instruments
Clinical Manifestations
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Dysuria (difficulty voiding)
Frequency (more than every 2 hours)
Urgency
Retention
Suprapubic pain, pressure, burning with
urination, flank pain, CVA tenderness,
abdominal discomfort (all from inflammation)
• Cloudy urine; frank hematuria
Clinical Manifestations cont’d
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Dribbling
Hesitancy
Incontinence
Nocturia; nocturnal enuresis
Weak stream
Confusion in elderly
Fever, chills, N/V, malaise if
pyelonephritis or urosepsis
Clinical Manifestations—Dx Tests
• Microscopic urinalysis reveals pyuria,
numerous WBCs, bacteria, +nitrites,
blood
• Urine culture obtained by clean catch
midstream or cath specimen shows
greater than 10,000 colony growth
• +Blood cultures (urosepsis)
• Imaging studies prn (IVP, CT, MRI)
Treatment
• Antibiotics—oral, IM, or IV. Type
empirically selected or by C & S testing.
Usually need to start ASAP, but may
need to change based on labs.
• Urinary analgesic
• Prophylactic antibiotic tx
Nursing Assessment
• Hx of UTIs, stones, dx procedures or
surgery, BPH
• Hygiene practices, S&S, sexual practices
• Urine appearance
• Labs or other dx tests
Nursing Diagnoses
• Impaired urinary elimination
• Ineffective therapeutic regimen
management
• Pain
• Risk for deficient fluid volume
Goals/Evals
• Pt will have relief from sx
• Pt will have no complications or spread
of UTI
• Pt will have no recurrence
Interventions
• Teach health promotion practices to
prevent UTIs:
– Empty bladder regularly and before and
after intercourse
– Good hygiene practices
– Fluid intake 15 mL/lb/day--20% from food
– Daily cranberry juice
– No douches, harsh soap, Bbaths, sprays
– Teach S/S UTI
Interventions cont’d
• Prevent hospital-aquired infections
(HAIs) by:
– Handwashing
– Avoid catheterization if possible
– Practice aseptic technique with procedures
– Good cath care and perineal hygiene
Interventions
• For acute care:
– Encourage fluids
– Avoid caffeine, ETOH, citrus, chocolate,
spicy—cause bladder irritation
– Heat application
– Administer antibiotics (will need 14-21
days) and analgesics
– Teach pt about meds and to continue
meds at home until all gone