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Mercy! MRSA!Mercy! MRSA!
Gail R. Hansen, DVM, MPHGail R. Hansen, DVM, MPH
State EpidemiologistState Epidemiologist
Kansas Department of Health and EnvironmentKansas Department of Health and Environment
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Before starting, Thanks!Before starting, Thanks!
Dr. Dan Hinthorn, KUMCDr. Dan Hinthorn, KUMC
Ms. Sheri Anderson, KDHEMs. Sheri Anderson, KDHE
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ts.Staphylococcus aureusStaphylococcus aureus
Gram positive cluster forming Gram positive cluster forming coccicocci
SourcesSources• Commonly carried on the skin and Commonly carried on the skin and
mucus membranes of humans mucus membranes of humans • Most common cause of skin Most common cause of skin
infections in USinfections in US
• A word about petsA word about pets
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DiseasesDiseases
TopicalTopical• CellulitisCellulitis
• BoilsBoils
• ImpetigoImpetigo
• Wound infectionsWound infections
Antimicrobials may Antimicrobials may not be necessary for not be necessary for treatmenttreatment
SystemicSystemic• BacteremiaBacteremia
• EndocarditisEndocarditis
• Toxic Shock Toxic Shock SyndromeSyndrome
Require antibioticsRequire antibiotics
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What is MRSA?What is MRSA?
MMethicillin-ethicillin-RResistant esistant SStaphylococcus taphylococcus aaureusureus
Resistant to other beta (ß) lactamase-Resistant to other beta (ß) lactamase-resistant penicillins and cephalosporins resistant penicillins and cephalosporins
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Staphylococcus aureusStaphylococcus aureus perspective perspective
Staphylococcus has been around as long as historyStaphylococcus has been around as long as history• Egyptian mummiesEgyptian mummies
• 1880s--usual cause of pus from wounds1880s--usual cause of pus from wounds
• Sulfa drugs reduced infections but resistance developedSulfa drugs reduced infections but resistance developed
• Penicillins reduced infections but resistance developedPenicillins reduced infections but resistance developed
Staph has virulence factors & defense mechanisms Staph has virulence factors & defense mechanisms that cause rapidly progressive diseases, even with that cause rapidly progressive diseases, even with normal immune systemsnormal immune systems
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ResistanceResistance
Staph have 1 of 5 Staph Cassette Staph have 1 of 5 Staph Cassette Chromosomes that hold resistance factorsChromosomes that hold resistance factors• SCC IV and V are small SCC IV and V are small
CA-MRSA, type IV.
• SCC I-III are largeSCC I-III are largeHA-MRSA types I, II, or III
• The SCCmec A IV (resistance gene to The SCCmec A IV (resistance gene to methicillin) can’t hold all types of resistances methicillin) can’t hold all types of resistances due to sizedue to sizeFirst described in S. epidermidis in the 1970s
New Resistant Bacteria
Mutations
XX
Emergence of Antimicrobial Emergence of Antimicrobial ResistanceResistance
Susceptible Bacteria
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Resistant Bacteria
Resistance Gene Transfer
Resistant StrainsRare
xx
Resistant Strains Dominant
Antimicrobial Exposure
xxxx
xx
xx
xx
Selection for antimicrobial-resistant StrainsSelection for antimicrobial-resistant Strains
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
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Staph has out-smarted us at Staph has out-smarted us at every turnevery turn
Able to make cell walls even though Able to make cell walls even though methicillin should prevent thatmethicillin should prevent that
Mortality was 70% before penicillin in 1937Mortality was 70% before penicillin in 1937• 1944, with penicillin--mortality 28% 1944, with penicillin--mortality 28%
• 1954, with 1954, with -lactamase--mortality 50% -lactamase--mortality 50%
• 1962, with methicillin--mortality 30% 1962, with methicillin--mortality 30%
S. aureusS. aureus is the #1 pathogen in children is the #1 pathogen in children
Evolution of Antimicrobial Evolution of Antimicrobial ResistanceResistance
S. aureus
Penicillin
(1950s)
Penicillin-resistant
S. aureus
Methicillin
Methicillin-resistant
S. aureus (MRSA)
Vancomycin-ResistantS. aureus
Vancomycin
Vancomycin -
intermediate
resistant
S. aureus
(1960s)
(2002)
(1997)
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PVL and severe diseasePVL and severe disease
The PVL gene (Panton Valentine The PVL gene (Panton Valentine Leukocidin) Leukocidin) • First described in 1894First described in 1894
• Further described by P&L in 1932Further described by P&L in 1932
• It codes for a cytotoxin against WBC & RBCIt codes for a cytotoxin against WBC & RBC
• PVL gene is not linked to SCCmec type IV PVL gene is not linked to SCCmec type IV Found in MSSA and MSSA with PVL Predated CA-MRSA.
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Toxins in staphToxins in staph
S. aureusS. aureus may have 30 extracellular products. may have 30 extracellular products. • Enzymes, cytotoxins, hemolysins etcEnzymes, cytotoxins, hemolysins etc
PVL, synergohymenotropic toxinPVL, synergohymenotropic toxin• Acts on cell membranes, forms a poreActs on cell membranes, forms a pore
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 typeIVSCCmecA typeIV Grows faster 5X more lethal than CA-MRSA without PVL
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Confusing names made easyConfusing names made easy
Names are by PFGE, not phage type, ~80/81Names are by PFGE, not phage type, ~80/81• CA-MRSA are called USA-300, USA-500, USA-CA-MRSA are called USA-300, USA-500, USA-
1000, USA-1100.1000, 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.HA-MRSA are called USA-100 USA-200. Most resistant to erythromycin, clindamycin, quinolones. Most susceptible to tetra and trimethsulfa.
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HA-MRSAHA-MRSA
Scottish study Scottish study • Increased new ICU cases of MRSA related toIncreased new ICU cases of MRSA related to
Nursing staff deficits Failure to use basic infection control practices Deficiency of environmental hygiene
160 sites cultured160 sites cultured Sinks, curtains, bedrails, computers 23% were positive 70% were positive from site where hand contamination
occurred.
Organisms usually viewed as environmentally Organisms usually viewed as environmentally spreadspread
VRE, vancomycin resistant enterococci CDAD, Cl. difficile associated diarrhea
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HA-MRSA TransmissionHA-MRSA Transmission
Person to person contact most important Person to person contact most important • Hands of staff, transiently colonizedHands of staff, transiently colonized
Environment plays a limited roleEnvironment plays a limited role• Equipment, surfacesEquipment, surfaces
Droplet-borne transmission is even less Droplet-borne transmission is even less commoncommon
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Factors that Favor HA-MRSA Factors that Favor HA-MRSA TransmissionTransmission
High resident to staff ratiosHigh resident to staff ratios Lack of attention to basic infection control Lack of attention to basic infection control
measuresmeasures Use of common equipment without Use of common equipment without
disinfectiondisinfection Personal item sharing among residentsPersonal item sharing among residents Limited facilities for handwashingLimited facilities for handwashing Inappropriate use of antimicrobialsInappropriate use of antimicrobials
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HA-MRSA PreventionHA-MRSA Prevention
Hand hygieneHand hygiene• Antiseptic washing Antiseptic washing
• Soap and waterSoap and water
• Waterless handrubs/alcoholWaterless handrubs/alcohol70% better than 95%Not for visible dirt
• Fake nailsFake nails
Beware donor fabricsBeware donor fabrics
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CA-MRSACA-MRSA
MRSA of persons who have not been MRSA of persons who have not been hospitalized in the past yearhospitalized in the past year
Usually skin infections in otherwise Usually skin infections in otherwise healthy peoplehealthy people
Virulence factors allow CA-MRSA to Virulence factors allow CA-MRSA to spread more easily or cause more skin spread more easily or cause more skin diseasedisease
25-30% of population colonized with 25-30% of population colonized with S. S. aureusaureus• 1% (?) with MRSA 1% (?) with MRSA
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CA-MRSA TransmissionCA-MRSA Transmission
Mostly via contaminated hands Mostly via contaminated hands • Contact with infected individuals Contact with infected individuals • Contact with contaminated environmental Contact with contaminated environmental
surfacessurfaces
Other risk factorsOther risk factors• Skin-to-skin contactSkin-to-skin contact• Crowded conditionsCrowded conditions• Poor hygienePoor hygiene
Environmental contaminationEnvironmental contamination• Not commonNot common
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The growth of CA-MRSAThe growth of CA-MRSA
MRSA reported 2 yr after methicillin was first MRSA reported 2 yr after methicillin was first used (1961)used (1961)• Predecessor to the USA300 strain Predecessor to the USA300 strain
MRSA infections started in community 1980’sMRSA infections started in community 1980’s• Aborigines in Australia, New ZealandAborigines in Australia, New Zealand
• Native American children in MN, NE, NDNative American children in MN, NE, ND
• MSM in LA, ATL, BostonMSM in LA, ATL, Boston
• Prisoners, athletes, wrestlers, football, fencersPrisoners, athletes, wrestlers, football, fencers
Majority of SSSI in ED across US now have CA Majority of SSSI in ED across US now have CA MRSA MRSA
most CA-MRSA appear to be resistant to β-lactams only
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CA-MRSA SyndromesCA-MRSA Syndromes
Necrotizing skin infections (spider bites)Necrotizing skin infections (spider bites) Necrotizing fasciitis (“flesh eating” like strep)Necrotizing fasciitis (“flesh eating” like strep)
• Pyomyositis with eos in Africa, & pyomyositis in HIV.Pyomyositis with eos in Africa, & pyomyositis in HIV. Septic thrombophlebitis of extremitiesSeptic thrombophlebitis of extremities Pelvic syndromes especially in childrenPelvic syndromes especially in children
• Septic arthritis of hipsSeptic arthritis of hips• Pelvic osteomyelitis Pelvic osteomyelitis • Pelvic abscessesPelvic abscesses• Septic thrombophlebitisSeptic thrombophlebitis
Waterhouse-Friderichson syndromeWaterhouse-Friderichson syndrome Rapidly progressive necrotizing pneumoniaRapidly progressive necrotizing pneumonia
• Develops in hours, even in previously health young people.Develops in hours, even in previously health young people.
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CA-MRSA PreventionCA-MRSA Prevention
Cover draining infectionsCover draining infections• HCW off work until open wounds healed.HCW off work until open wounds healed.
Wash hands Wash hands • during day during day
• after toileting after toileting
• before eatingbefore eating
Don’t share personal itemsDon’t share personal items
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CA-MRSA PreventionCA-MRSA Prevention
Wash linens in hot waterWash linens in hot water Dry clothes in hot dryer, not air dryingDry clothes in hot dryer, not air drying Shower after group sports, gym use, Shower after group sports, gym use,
sauna, steam room or tanning sauna, steam room or tanning • With draining wounds, no athletic With draining wounds, no athletic
competition competition
• Clean communal surfaces at gymClean communal surfaces at gym
Immunization so far not effectiveImmunization so far not effective
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Spider bite or MRSA?Spider bite or MRSA?
Start with an itch, then painfulStart with an itch, then painful Get worse and not better with local Get worse and not better with local
treatmenttreatment Both have central necrosisBoth have central necrosis
• Look blackish or dark red or purple in centerLook blackish or dark red or purple in center
Surrounding induration and erythemaSurrounding induration and erythema Slow to resolveSlow to resolve
• Neither Keflex nor Dapsone workNeither Keflex nor Dapsone work
Did you see the spider?Did you see the spider?
Photo courtesy of Dr. D. Hinthorn, KUMC
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Treatment for MRSATreatment for MRSA
Incise and drain abscessesIncise and drain abscesses Culture, culture, culture!Culture, culture, culture!
• Results of susceptibility determine antimicrobialsResults of susceptibility determine antimicrobials
Antimicrobials Antimicrobials • VancomycinVancomycin
VRSA and VISA
• Trimeth-sulfaTrimeth-sulfa
• Doxy or minocyclineDoxy or minocycline
• ClindamycinClindamycin
• Quinolones? NoQuinolones? No
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SurveillanceSurveillance
Communication between facilities about MRSA + Communication between facilities about MRSA + patients patients
Review culture and susceptibility dataReview culture and susceptibility data Maintain confidential line listing of MRSA + Maintain confidential line listing of MRSA +
patientspatients Flag MRSA+patients to assist with precautionsFlag MRSA+patients to assist with precautions Active surveillance cultures for MRSA?Active surveillance cultures for MRSA?
• Not be a routine measure Not be a routine measure • Maybe during an outbreakMaybe during an outbreak• Routine culture and treatment in hospitals not effective Routine culture and treatment in hospitals not effective
in reducing MRSAin reducing MRSA
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Reporting RequirementsReporting Requirements
Single cases of MRSA are not reportable in Single cases of MRSA are not reportable in KS or MOKS or MO
Outbreaks are reportable in KS and MOOutbreaks are reportable in KS and MO Other states differentOther states different
• VRSA or VISA reportable from any siteVRSA or VISA reportable from any site
• MRSA reportable if isolated from sterile siteMRSA reportable if isolated from sterile site
• S. aureusS. aureus reportable if it results in a serious infection reportable if it results in a serious infection resulting in death or admission to ICUresulting in death or admission to ICU
• MRSA labs reportable onlyMRSA labs reportable only
• All MRSA infection reportableAll MRSA infection reportable
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ts.MRSA Outbreaks MRSA Outbreaks
2 or more patients with MRSA infection 2 or more patients with MRSA infection that are epidemiologically linkedthat are epidemiologically linked• Roommates in LTC, cared for by the same Roommates in LTC, cared for by the same
staffstaff• 2 members of the football team2 members of the football team
Infections have temporal relationshipInfections have temporal relationship Call KDHE-OSE at 877-427-7317Call KDHE-OSE at 877-427-7317
• Report outbreak or request assistanceReport outbreak or request assistance
QuestionsQuestions??
??
877-427-7317877-427-7317
