Melissa Wilson
RN BSN FNP-S
• Methicillin-resistant Staphylococcus Aureus (MRSA) is a type
of staph bacteria that is resistant to certain antibiotics called
beta-lactams.
• These antibiotics include methicillin and other more common
antibiotics such as oxacillin, penicillin, and amoxicillin.
• In the community, most MRSA infections are skin infections.
• More severe or potentially life-threatening MRSA infections
occur most frequently among patients in healthcare settings.
• While 25% to 30% of people are colonized* in the nose with
staph, less than 2% are colonized with MRSA.
(Gorwitz, 2008)
• You can be "colonized" with MRSA, meaning that you carry
the bacteria on your skin or in your nose but you have no signs
or symptoms of the illness.
• Staphylococcus aureus is a bacterium that lives normally on
human skin surfaces – in fact 40% of us have the little guys all
over us right now as we sit here in front of our computers.
• MRSA, which is simply an antibiotic resistant strain of
Staphylococcus aureus, can also live on our skin for long
periods or even permanently without us ever knowing it.
• This is called colonization, and depending on the population
group/risk profile most studies show that 5-10% of us are
carrying MRSA around with us wherever we go.
Up to date, 2013
• As far as sites of colonization these bacteria can live on
virtually any skin surface, but they really love the warmest,
dampest, darkest areas they can find including the nose, throat,
armpits, and various sites “south of the border”.
• It is widely accepted in the medical community that the nose
represents the primary reservoir of S. aureus/MRSA
colonization in humans, with the throat emerging as another
important area and all other sites considered secondary.
(Street, 2010)
Hospital Acquired MRSA (HA-MRSA) has a distinct
difference from Community Acquired MRSA (CAMRSA)
• Current evidence indicates that these CA-MRSA strains
are genetically distinct from hospital-acquired MRSA
(HA-MRSA), and that several unique communityacquired clones emerged simultaneously in different
locations in the world (Vandenesch, 2003).
• CA-MRSA infections occur in otherwise healthy
people without traditional risk factors
• CA-MRSA cause a different spectrum of illness than HA-MRSA, and some
CA-MRSA strains may be more virulent. CA-MRSA frequently causes skin
and soft tissue infections (SSTI), however, CA-MRSA also can be
associated with severe invasive disease (e.g., bacteremia/sepsis syndrome,
pneumonia, pyomyositis, bone and joint infections, endocarditis, necrotizing
fasciitis) (Naimi, 2003)
• Two genes are unique to CA-MRSA isolates and shared by isolates from
three continents: a type IV SCCmec cassette and the PVL locus (PantonValentine leukocidin).
• CA-MRSA have different antibiotic susceptibility patterns from HAMRSA; CA-MRSA are resistant to methicillin but generally are not multidrug resistant. Many are sensitive to trimethoprim-sulfamethoxazole,
clindamycin, aminoglycosides and quinolones.
(Naimi, 2003)
• The organism may cause disease through tissue invasion and
toxin production.
• The toxins liberated by the organism may have effects at sites
distant from the focus of infection or colonization.
• The organism is then disseminated via hand carriage to body
sites where infection may occur (either through overt breaks in
dermal surfaces, such as vascular catheterization or operative
incisions, or through less evident breakdown in barrier
function, such as eczema or shaving-associated micro-trauma).
NIH, 2008
• Beta-lactam antibiotics inhibit the growth of sensitive bacteria by
inactivating enzymes located in the bacterial cell membrane, which are
involved in the third stage of cell wall synthesis.
• It is during this stage that linear strands of peptidoglycan are cross-linked
into a fishnet-like polymer that surrounds the bacterial cell and confers
osmotic stability in the hypertonic milieu of the infected patient.
• Beta-lactams inhibit not just a single enzyme involved in cell wall synthesis,
but a family of related enzymes (four to eight in different bacteria), each
involved in different aspects of cell wall synthesis.
• These enzymes can be detected by their covalent binding of radioactivelylabeled penicillin (or other beta-lactams) and hence have been called
penicillin binding proteins (PBPs).
• Methicillin-resistant Staphylococcus is a virulent strain of S.aureus that
disinhibits the effects of beta-lactams on this particular bacterium (National
Institute of Health [NIH], 2008, p. 350-359).
• Methicillin-resistant Staphylococcus aureus has resulted from
decades of prescribed antibiotics for treatment when
unnecessary.
• For many years, prescriber’s have treated colds, flu and other
viral infections with antibiotics that do not respond to these
medications.
• Even when antibiotics are prescribed appropriately there is a
contributory rise in drug-resistant bacteria because the
antibiotics do not destroy all of the germs that the drug is
targeting.
• Bacteria are evolutionary organisms that learn to survive
treatment of one antibiotic and learn to resist others
(“MayoClinic,” 2013).
• The most recent statistics find that the in 2011 there were
80,500 cases of infections in the United States as opposed to
111,300 in the year 2005.
• Overall the serious diagnosed cases in the hospitals dropped by
54% between the years 2005-2011.
• In the year 2005 there were 9.7 cases per 100,000 and in the
year 2011 there were only 4.5 cases per 100,000.
• Incidence of individuals developing MRSA after being
discharged from the hospital or being associated with a
healthcare facility fell 28% during that same
Seaman, 2013
• In 2005 there were 21 infections per 100,000 and in 2011 there
reported cases were 15 per 100,000.
• In the development of CA-MRSA the cases reported in 2011
were estimated at 16,560 and were an average of 5.32 patients
per 100,000.
• It is difficult to track the number of CA-MRSA because many
of the cases go unreported
(http://www.cdc.gov/mrsa/tracking/index.html).
Seaman, 2013
• Being hospitalized. MRSA remains a concern in hospitals,
where it can attack those most vulnerable — older adults and
people with weakened immune systems.
• Having an invasive medical device. Medical tubing — such
as intravenous lines or urinary catheters — can provide a
pathway for MRSA to travel into your body.
• Residing in a long-term care facility. MRSA is prevalent in
nursing homes. Carriers of MRSA have the ability to spread it,
even if they're not sick themselves.
Mayo Clinic, 2013
• Participating in contact sports. MRSA can spread easily
through cuts and abrasions and skin-to-skin contact.
• Living in crowded or unsanitary conditions. Outbreaks of
MRSA have occurred in military training camps, child care
centers and jails.
• Men having sex with men. Homosexual men have a higher
risk of developing MRSA infections.
Mayo Clinic, 2013
• Depends on the site infected:
• Skin: Swelling, erythema, pain, purulent drainage, pus, fever,
inflammation, necrosis, boils, bullae, furuncles, carbuncles, folliculitis and
abscesses. Rash may appear as broken blood vessels under the skin.
• Joints: Redness, warmth, swelling, pain and fever, pain worse with
movement, and inability to move the joint
• Lungs: Fever, cough, yellow/green/tan sputum, shortness or breath, painful
breathing and pleuritic pain, N&V, weakness, fatigue, tachycardia, body
aches, and rapid breathing.
• Heart: Anorexia, back pain, fever, excessive sweating at night, weight loss,
rapid pulse, rash, headache, malaise and fever.
• Bone: Pain, tenderness, chills, fever, swelling, redness and bone tenderness.
• Blood: Sepsis, anorexia, fever, muscle aches, fatigue, SOB, rapid
respirations and pulse, rash, confusion and coma.
Epocrates, 2013
MRSA. The differential
diagnosis for MRSA are as follows:
• Animal or human bites,
•
• brain abscess, Cellulitis,
•
• Decubitus Ulcer,
•
• Diabetic Ulcer,
•
• liver abscess,
•
• myocardial abscess,
•
• osteomyelitis,
•
• Sepsis
MD Guidelines, 2013
perianal abscess,
septic arthritis,
Pinal cord abscess,
streptococcus infections,
urinary tract infections and
wound infections
Pneumonia
HA-MRSA.
• In the hospital, people who are infected or colonized with
MRSA often are placed in isolation as a precaution to prevent
the spread of MRSA.
• Visitors and health care workers caring for people in isolation
may be required to wear protective garments and must follow
strict hand hygiene procedures.
• Contaminated surfaces and laundry items should be properly
disinfected.
• Social isolation can have an impact on the patients self image.
CDC, 2013
CA-MRSA:
• These community-associated MRSA (CA-MRSA) infections have
been identified in a variety of populations, including: athletes
participating in close contact sports, military recruits in barracks
settings, intravenous drug users, men who have sex with men, tattoo
recipients, religious community members, and inmate populations.
• Moreover, many healthy adults and children—without any obvious
risks for exposure—are also developing MRSA infections.
• In most communities in the U.S., MRSA is the leading cause of skin
and soft tissue infections (SSTIs) among persons seeking emergency
care ( BOP, 2012, p. 1).
• The way to screen for MRSA is through cultures and biopsies
of the infected area.
• If the patient develops a skin infection screening is done by
taking a culture of the infected area.
• Suspicion of a respiratory infection or pneumonia a sputum
culture is obtained.
• Often blood cultures are obtained when septicemia is suspected
and aseptic technique is used to obtain a urine culture.
• Individuals who are at risk for developing MRSA or have a
history of MRSA are often screened prior to hospitalizations or
surgical procedures.
Up to Date, 2013
CA-MRSA can be distinguished from HA-MRSA by using the
following criteria:
• Diagnosis of MRSA is made in the outpatient setting or by a culture
positive for MRSA within 48 hrs. of hospital admission, AND
• The patient has no past medical history of MRSA infection or
colonization, AND
• The patient has no past medical history in the past 1 year of:
Hospitalization
Admission to a nursing home, skilled nursing facility, or
hospice
Dialysis
Surgery
Permanent indwelling catheters or percutaneous medical
devices
Naimi,2008
• Keep your hands clean by washing thoroughly with soap and
water or using an alcohol-based hand rub.
• Keep cuts and scrapes clean and covered with a bandage until
healed, avoid contact with other people’s wounds or bandages,
maintain a clean environment washing surfaces that come into
contact with your skin and
• avoid sharing personal items such as towels or razors (CDC,
2013).
• Hospitalized people with MRSA infections are usually treated
with an intravenous medication.
• The intravenous antibiotic is usually continued until the person
is improving.
• In many cases, the person will be given antibiotics after
discharge from the hospital, either by mouth or by IV.
• This may be needed for a short period of time or for as long as
six to eight weeks.
• Intravenous antibiotics can be given at home, by a visiting
nurse, or in a rehabilitation facility.
• Nares may be swabbed with topical Mupirocin if patient is
positive for MRSA in the nose.
CDC, 2013
• Treatment of MRSA at home usually includes a seven to 10 day
course of an antibiotic (by mouth) such as trimethoprimsulfamethoxazole (brand name: Bactrim), clindamycin, minocycline,
or doxycycline.
• In addition to antibiotics, your healthcare provider may drain the
infected area by inserting a needle or making a small cut in the skin.
• This is done to reduce the amount of infected material (pus), which
will help the tissue to heal.
• In some cases additional strategies may be used for management of
household spread and/or recurrent infection.
• These may include use of mupirocin ointment, chlorhexidine soap,
and other techniques. These strategies are not always fully effective.
CDC, 2013
• Defining MRSA complications is complex because it is
dependent on the system that it affects.
• MRSA infections can resist the effects of many common
antibiotics, so they are more difficult to treat.
• This can allow the infections to spread and sometimes become
life-threatening.
• MRSA infections may affect your: bloodstream, lungs, heart,
bones and joints and potentially be fatal ("Mayo Clinic," 2013).
Necrotizing Fasciitis:
Skin swelling and redness
• Skin discoloration
• Skin may turn black
• Skin blisters: May appear as
purple or blood*filled blisters
• Severe skin pain
• Muscle pain
• Severe swelling beneath the skin
MD Guidelines, 2013
• Drainage from the skin:
• Red or brown fluid draining from
the skin
• Pus draining from the skin
•
•
•
•
•
Fever
Weakness and fatigue
Anorexia
Rapid pulse
Malaise
Google Images, 2013
• Follow up will be different dependent on how serious the
MRSA infection is.
• Patients who are treated in the hospital may be sent home with
on IV antibiotics or oral antibiotics and will be followed up
weekly.
• Follow up with Infectious Disease (ID) may be necessary.
• Patients with CA-MRSA may be treated with topical
ointments, surgical incisions and oral antibiotics. These
patients are followed up after 7-10 days.
• Surgical consult may be necessary for SSTI’s and non-healing
wounds for debridement.
• Contact your health care provider if you think you have an
infection so it can be treated quickly. Finding infections early
and getting care will decrease the chance that the infection will
become severe.
• Signs of infection include redness, warmth, swelling, pus, and pain at
sites where your skin has sores, abrasions, or cuts. Sometimes these
infections can be confused with spider bites.
• Infections can also occur at sites covered by body hair or where uniforms
or equipment cause skin irritation or increased rubbing.
• Do not try to treat the infection yourself by picking or popping
the sore.
CDC,2013
• Cover possible infections with clean, dry bandages until you
can be seen by a doctor, nurse, or other health care provider
such as an athletic trainer.
• Cover your wounds. Keep wounds covered with clean, dry
bandages until healed. Follow your doctor’s instructions about
proper care of the wound. Pus from infected wounds can
contain MRSA so keeping the infection covered will help
prevent the spread to others. Bandages and tape can be thrown
away with the regular trash.
CDC,2013
• Clean your hands often. You, your family, and others in close
contact should wash their hands often with soap and water or
use an alcohol-based hand rub, especially after changing the
bandage or touching the infected wound.
• Do not share personal items. Personal items include towels,
washcloths, razors, clothing, and uniforms.
• Wash used sheets, towels, and clothes with water and laundry
detergent. Use a dryer to dry them completely.
• Wash clothes according to manufacturer’s instructions on the
label.
CDC,2013
1. MRSA describes a specific type of bacteria that are
resistant to certain antibiotics. True or False
2. Is MRSA contagious? Yes or No
3. A commonly used word to describe MRSA is...
a) Superbug
b) E coli
c) Salmonella
d) Rash
MRSA Infection,2013
4. MRSA bacteria are most likely found...
a) The community
b) The hospital
5) Some of us carry MRSA bacteria in our...
a) Mouths
b) Noses
c) Eyes
d) Throats
6) What is the best defense against MRSA?
a) Good hygiene
b) Vaccines
c) Avoiding antibiotics
d) All the above
MRSA Infection,2013
7). MRSA most often enters the body through droplets from coughing or
sneezing. True or False
8). MRSA can cause sepsis, which is an infection of the blood. True or
False.
9). A MRSA skin infection can often mimic a ________________.
a) cut
b) Scrape
c) Spider bite
d) Stye
10). MRSA infections can cause complications such as...
a) “flesh eating” disease
b) Pneumonia
c) Death
d) All of the above
MRSA Infection,2013
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Methicillin-resistant Staphylococcus Aureus (MRSA) Infections. (2013). Retrieved from http://www.cdc.gov/mrsa/
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