understand What is MRSA- TO -Manage it

1. Prepared and presented by:
Dr Soha Adloni
MS.c Clinical Pharmacy

2. What is MRSA?
 Staphylococcus aureus or “Staph” bacteria that commonly
lives on the skin and in noses of healthy people.
 usually staph bacteria are harmless
 staph bacteria may cause an infection
 If they enter the body through a break in skin
 infections can usually be treated with antibiotics

3. What is MRSA?
MRSA: Methicillin-Resistant Staphylococcus aureus
MRSA is a type of staph bacteria that has become
resistant to methicillin and many other antibiotics
traditionally used against S. aureus.
They can range from very minor to life-threatening
They live on surfaces for several days

4. Basic characteristic of S.aureus
Gram positive
Non-motile
Spherical clusters (clumps of grapes)
Golden color, purple on stain
Hemolytic on blood agar
Produces coagulase and catalase
enzymes

5. Virulence factors: avoiding host defensive
mechanism
Cell wall
Cytoplasmic membrane-osmotic barrier prevents disequilibrium
of ionic content. Preventing cell osmotic instability and
susceptibility to lysis
Polysaccharide capsule-slime layer; adhesion, inhibits
phagocytosis
Peptidoglycan allows bacteria to attach to host’s cell membranes.

6. History of S. aureus resistance
1941 Introduction of penicillin into treatment of infectious diseases
1944 S.aureus penicillin resistant
1960 new Penicillinase-resistant drugs used to fight Staph. e.g. Methicillin
1975 Methicillin resistance strains of S.aureus emerge
1988 2.4 % S.aureus are methicillin resistance
1989 3% Enterococcus Vancomycin resistant (VRE)
1991 29% S.aureus methicillin-resistance
1993 7.9 % VRE
1996 S.aureus strain intermediate Vancomycin-resistance
1998 Man in N.Y dies from S.aureus
2000’s CA-MRSA emerged (USA reported 300 cases)

7. What are the infection with MRSA ?
Most commonly: skin infections (including
SSI), soft tissue (necrotizing fasciitis)
 Bacteremia, infective endocarditis –sever
 Pneumonia (rare cases)
Bone & joint: Osteomyelitis, Septic Arthritis,
Device-related)
CNS (meningitis, brain abscesses)- sever

8. How does MRSA spread?
 Through direct contact with the skin of carrier, personal items of carrier, objects
of MRSA
 Responsible for 94,000 life threatening infections and 18,650 deaths in 2005
(more than AIDS)
 2 – 10% population colonized with MRSA

9. Column %
Pathogen
CLABSI
11,428
CAUTI
9,377
VAP
5,960
SSI
7,025
Total*
33,848
CoNS 34 3 1 14 15
S. aureus 10 2 24 30 14
Enterococcus spp. 15 15 1 11 12
Candida spp. 12 21 <1 2 11
E. coli 3 22 5 10 10
P. aeruginosa 3 10 16 5 8
K. pneumoniae 5 8 7 3 6
Enterobacter spp. 4 4 8 4 5
A. baumannii 2 1 8 1 3
Distribution and Rank Order of 9 Most Common Pathogens Reported
for 28,502 HAIs, NHSN 2006-2007
15.6% of healthcare-associated infections had >1 pathogen (polymicrobial)
*
Hidron et al. Infect Control Hosp Epidemiol 2008;29:996-1011

10. Who is at risk for MRSA?
ANYONE …..can get MRSA
Those most at risk;
Spend vast time in crowded places (hospitals, schools, dorms,
military, native populations)
Share sports equipment
Share personal hyiegene items
Play contact sports
Overuse or misuse Antibiotics
Age > 65 years

11. Can healthy people get MRSA?
25 – 30% population is
colonized in the nose
with MSSA at a given
time of ≥ 3 mon.

12. Can healthy people get MRSA?
Play contact sports
43% of all skin
infections are the
result of one strain of
MRSA

13. Can healthy people get MRSA?
Share personal hyiegene items

14. Share sports equipment
Can healthy people get MRSA?

15. Can healthy people get MRSA?
Spend vast time in hospitals
Most common:
SSI 30%
VAP 24%
HA-MRSA:
49 – 65%

16. Can healthy people get MRSA?
CA-MRSA has been found colonized in cats and dogs, they can
possibly be infected and reinfect the pet owners.

17. Can healthy people get MRSA?
Michael did !!

18. NOW
PANIC
AND
FREAK
OUT

19. Can healthy people get MRSA?
YES
Community-Associated MRSA (CA-MRSA) has
been reported among: athletes, prisoners, and
military recruits.
Outbreaks: schools, gyms, day care centers and
HIV.
CA-MRSA has been found in cats and dogs and
possibly reinfect the pet owners.

20. The antibiotic resistance
Why: How:
Unnecessary antibiotic use
Antibiotics in food and water
Germ mutation: Antibiotics
don’t destroy every germ they
target. mutate much more
quickly than new drugs can
be produced.
Transfer factors: survival of
the fittest-quantum
communication
Presence of mec gene in the
bacteria
It alters the site at which
methicillin binds to kill the
organism
As a result methicillin and
other antibiotics can not bind
to bacteria.

21. CA-MRSA Vs. HA-MRSA
CA – MRSA HA – MRSA
 Spreads more easily
 Cause more skin diseases
 Susceptible to Clindamycin,
tetracycline, bactrim
 Common in USA ( USA 300)
known resistance to most
antibiotics
 Has virulence factors (necrotizing
pneumonia, skin, soft tissue
infections)
 Hospitals can encounter CA-MRSA
as well.
 More resistant to Antibiotics
 Less mobile
 Transmitted :
 direct contact
 fluids
 procedures
Indirect contacts

22. Risk factors for acquiring HA-MRSA
 Break in natural skin barrier.
 surgery (especially implants)
 bedsores
 Invasive contaminated devices and procedures
 IV catheters
 Urinary catheters
 Intubation
 Overuse of Antibiotics (combination in prophylaxis
management)
 Patients with comorbidities

23. Colonization Vs. infection
S. aureus colonization
 on/in body without illness
 0.9 – 13.2% health care workers are colonized
 25 – 30% are colonized in nose at a given time ~ ≥ 3 months
S. Aureus infection
 once colonized > 3 months and infects, becomes difficult to treat.
 30 – 60% colonized patients risk of infection
 Host factors influence the onset of infection, e.g. immunosupression,
steroids, DM, invasive devices, surgery, skin breakdown, PNA,
obesity, hematoma.

24. Prevention is Better Than
Cure

32. Modeled Incidence and Percent Change for All Invasive Hospital-Onset
and Healthcare-Associated, Community-Onset MRSA infections, 2005-
2007
Year Modeled
incidence per
100,000
population
Modeled
percent
change from
previous year
Total modeled
percent
change
P-value
Hospital-onset
2005 9.95
2006 8.96 -9.97%
2007 8.24 -8.08% -17.2% 0.01
Healthcare-associated, community-onset
2005 22.13
2006 21.11 -4.59%
2007 19.70 -6.71% -11.0% 0.04
Kallen AJ, et al, SHEA 2009, Abstract 49

34. How can MRSA be prevented?
 Wash hands
 Personal items
 Wounds clean and covered
 Shower after athletic games and practices
 Sanitize linens
 Use antibiotics appropriately and safely

35. Researches and data:
 75% of MRSA are CA-MRSA
 Responsible for 94,000 life threatening infections and 18,650 deaths in 2005
(more than AIDS)
 New lethal strain emerges: 50% cases death among MRSA 600 (Henry ford
hospital, Florida, USA-2007)
 Ordinarily 11% of patients infected with MRSA die in 30 days without
controlled management and presence of factors (age > 64, untreated, or
complications)

36. Treatment

37. Treatment
The management of all MRSA infections should include:
Identification
Elimination
and/or Debridement
of the primary source

38. Outpatient management of skin and
soft tissue infections in CA-MRSA
 signs/symptoms of skin
infection:
•redness
Swelling•
Warmth
Pain/tenderness•
Complaint of ”spider bite”
 With lesion purulent
Fluctuance-palpable
•Yellow or white center•
Central point or “head”
Draining pus
If systemic symptoms, severe
local symptoms,
immunosupression, or failure to
respond to I&D
Provide antimicrobial therapy
with coverage for
Streptococcus spp.
Consider adding coverage for
MRSA (if not provided initially)
Maintain close follow-up

41. Decolonization treatment

43. Decolonization treatment (1)
1. Use small mupirocin tube each time you apply
to your nose (about 1/2 of the small tube to each
nostril).
2. Apply a pea-sized amount of mupirocin nasal
ointment inside each nostril. Use a clean finger or
a Q-tip to apply
3. Press your nostrils together and massage for
about 1 minute.
4. Avoid contact with your eyes as this could cause
irritation.
5. If some medicine gets into your eyes, rinse them
thoroughly with cool water
6. Apply the nasal ointment twice daily for 5 days.
7. Do not use any other topical nasal medications
for the 5 days of treatment.

44. Decolonization treatment (2)
Method of application
 Shower or bathe with Hibiscrab ® for each day that
you use the nasal ointment using a freshly laundered
wash cloth and towel each time
 Ensure all skin surfaces are well covered when using
the body wash.
 Shampoo your hair with regular shampoo first,
ensure that hair and body are wet.
 Use 2 packets water wash for each shower or bath.
Each packet contains about 1 tablespoon of the soap
 Apply the Hibiscrab ® as you would any other liquid
soap . Leave the soap on your skin for 1-2 minutes.
 Apply lotion all over hair and body, paying special
attention to armpits groin and feet.
 Rinse completely after the shower or bath.
 Avoid contact of the soap with your eyes as it cause
irritation
 Dry with a clean, dry towel.
 Discard all empty packages in your regular garbage.
After each shower put on clean clothes and sleep on
freshly laundered sheets Ensure all bed linen and
towels are changed daily and washed on the highest
possible temperature.
Hibiscrab ® (4% chlorhexidine) soap
shower / bath

45. In conclusion ……..
MRSA is increasing in the community and in Hospitals
Over use of antibiotics has created some of the problem
Resistance among species is evolving
Close quarters, equipment, environment and
contaminated hands are sources for transmission
Limited antibiotics available to treat MRSA
Pre-surgical screening program is an effective method of
detection for treatment and precautions

46. http://www.youtube.com/watch?v=vL6wI4pX
840#t=10