CA-MRSA & HA-MRSA

Rattlesnake-type Poisons Used By Superbug Bacteria To Beat Our Defenses

Colonies of hospital super-bugs can make poisons similar to those found in rattlesnake venom to attack our bodies' natural defences, scientists heard September 8, 2008 at the Society for General Microbiology's Autumn meeting being held at Trinity College, Dublin.

The bacteria manufacture the toxins in communities called biofilms, which can form in patients' bodies and are a thousand times more resistant to antibiotics than free-floating bacterial cells. The biggest risk from biofilms is likely to be when a piece of the community breaks free, causing infections in patients who suffer from long-term conditions.

Antibiotic & Biocide Resistant MRSA

New wave of ultra-resistant super bacteria has emerged. This bacteria is even more powerful versions of killers such as MRSA after it emerged the bacteria can become immune to powerful biocides as well as antibiotics. If weak doses of the bacteria-killing chemicals are used or solution not used for properly observing drying time some of the bugs survive and mutate to become stronger, a US study found.

Bacteria are said to have built-in 'efflux pumps' that expel toxic substances and remove antibiotics. Using this process this bacteria is now immune to biocides (Antiseptics and antibacteral).

Exposure to low concentrations of a variety of biocides resulted in the appearance of resistant mutants. Despite warning from microbiologists, healthcare providers are continuing to use alcohol wipes to prepare skin but do not follow strict guidelines (like observing drying time) before injecting medication or inserting intra-venous cannula & catheters. Using ported cannula to inject antibiotic can result in serious septicaemia because some low concentration antibiotics left in the port gives the bacteria an opportunity to develop resistance.

FACTS ABOUT CA-MRSA

• Rate has appeared to plateau, anecdotally at least, after an increase beginning about three years ago.
• It used to be in high school athletes, but it's working its way down to younger students,"
• The bacteria is transmitted by skin-to-skin contact or by touching an item that has come into contact with someone's infection.
• In general, schools are not a risk for the average student, but athletic environments — gyms, locker rooms and showers — are a risk setting.
• Staph infections, including the CA-MRSA strain, are not reportable conditions to public health officials. Only clusters are tracked by the state Department of Health and Environmental Control.
• Last winter, a few area high school students were treated for CA-MRSA, but the cases were not related and not reported to officials as a cluster.
• The last reported cluster in the region occurred in 2006.
• CA-MRSA initially occured in kids and young adults,  now seen in infants.
• Infections begin as a minor cut or sore that does not heal and may worsen rapidly into an abscess.
• Most transmissions are among members of the same household. Once CA-MRSA colonizes someone, there is the likelihood of colonizing everyone in the household.
• Physicians must culture most skin and soft tissue infections, especially boils, and begin antibiotic therapy as if CA-MRSA was the cause.
• Doctors often drain boils without culturing, which this day and time may be incomplete.

Methicilline Resistant Staphylococcus Infection (MRSA)

Methicillin resistance was first detected in S. aureus in 1961 (Guildford & Kettering in UK), shortly after the agent was introduced clinically, and over the last four decades, there has been a global epidemic of MRSA. MRSA produce biofilms, which are up to a thousand times more resistant to antibiotics than free-floating single bacterial cells. Bacteria lives in this environment and protect themselves. Bactericidal agents, antiseptic lotions and antibiotics cannot penetrate this biofilm. Vigorous washing and scrubbing dislodge biofilm from skin. When bacteria dislodged from the biofilm enters blood stream, they release toxins that can destroy white cells, produce blood clots, bleeding, shock, liquefy tissue and kill in 12-24 hours.

"This is the first time that anyone has successfully proved that the way the bacteria grow – either as a biofilm, or living as individuals – affects the type of proteins they can secrete, and therefore how dangerous they can potentially be to our health," says Dr Martin Welch from the University of Cambridge, UK.

Most MRSA infections was thought to occur in the hospitals or other health care settings, such as nursing homes and dialysis centres. It's was known as health care-associated MRSA, or HA-MRSA. Older adults and people with weakened immune systems are at most risk of HA-MRSA.

However, there has been an increase in MRSA infections presenting in the community that has not been properly addressed. People have been made to believe by tabloid news papers and the ministers, MRSA is a problem associated with "Dirty hospitals".

These MRSA strains are typical of the local healthcare-associated HA-MRSA and may be carried asymptomatically by patients for months after discharge. However, new strains of MRSA have recently emerged that cause infections in community patients who have no previous history of direct or indirect healthcare contact. These strains have been designated CA-MRSA.

Many in the UK at the present time, MRSA infections that appear to have a community onset occur in patients who are found to have had direct or indirect contact with hospitals, care homes or other healthcare facilities.

The trend in USA is not similar, CA-MRSA is rapidly become the major cause of common skin infections. Knowing the world population is now five times higher than in 20th century. We expect death rate from this infection to be very high due to over crowding, close contact, global warming and contaminated hospital waste polluting our earth. WHO has estimated potential worldwide death toll ranges from 7.4 million to 180 million to 360 million, extrapolating 1918’s deaths to today’s population. Given global air travel, the virus & bacteria could spread swiftly, possibly reaching all continents in three months, the WHO asserts. The federal government fears that 9 million Americans may become sick and have started planning for this evantuality.

Possibly most worrying about this is that the Centres for Disease Control in Atlanta, USA has stated that for the first time in history those born after the year 2000 are expected to die before their parents — a truly frightening prospect.

HA-MRSA (Healthcare Associated MRSA)

Strains that are transmitted to and circulate between individuals who have had contact with healthcare facilities. These infections can present in the hospital or healthcare setting (hospital or healthcare onset) or in the community (community onset), for example after hospital discharge.

MRSA strains isolated from patients in an outpatient or community setting (community onset), or within 48 h of hospital admission (hospital onset). Patients also typically have no previous history of MRSA infection or colonization, hospitalization, surgery, dialysis or residence in a long-term care facility within the previous year, and absence of indwelling catheters or per-cutaneous devices at the time of culture.

CA-MRSA (Community-Associated MRSA)

Has occur  among otherwise healthy adults and children in the wider community. CA-MRSA, is responsible for serious skin and soft tissue infections and for a serious form of pneumonia. This infection can kill healthy adults and children within 12-24 Hours.

CA-MRSA strains are genetically and phenotypically distinct from HA-MRSA. They typically resemble some strains of methicillin-susceptible S. aureus (MSSA) in being susceptible to a wider range of anti-staphylococcal antibiotics (some are resistant only to β-lactams), and often produce PVL, a toxin that destroys white blood cells and is a staphylococcal virulence factor.

This bacteria produces common skin infections, rapidly progressive severe pneumonia and tissue necrosis. Although other serious manifestations like Staphylococcus meningitis of these infections are emerging. Serious S. aureus infections can be caused by strains that are methicillin-resistant or -susceptible and which may or may not express the pathogenic Panton–Valentine leucocidin (PVL) toxin.

PVL-producing strains of CA-MRSA appear to be associated with increased risk of transmission, complications and hospitalization. For example, in one large community outbreak of CA-MRSA, 23% of patients required hospitalization. PVL has a clear role in the pathogenesis of severe necrotizing pneumonia and is associated with greater pulmonary and bone-related complications. Its role in skin infections is less certain. PVL is a potent toxin is a potent dermato-necrotic (liquefy skin and muscles) toxin and these organisms rapidly spread at home.

• PVL is a potent toxin

• Rattlesnake-type Poisons

In the UK, the overall prevalence of S. aureus strains that carry the gene for PVL production is believed to be <2%, and these are mainly MSSA (Methicilline Sensitive Staphylococcus Aureus).

Although the overall prevalence of CA-MRSA is said to be low worldwide, there is clear evidence that this is increasing, particularly in the USA, Canada and Australia. In some areas of the USA, a significant proportion of serious S. aureus infections presenting in community practice or at accident and emergency departments is now due to CA-MRSA types.

There are also emerging reports of CA-MRSA from Europe, including Scandinavian countries that have, until now, been almost free of HA-MRSA. There have been relatively few reports of CA-MRSA from the UK, but experience elsewhere suggests that these are likely to increase in the future.

We hope this website will help healthcare workers and you diagnose early, manage, isolation, prevention and spread this major infection in the community.

However, in USA the boundaries between HA-MRSA and CA-MRSA are becoming blurred due to the movement of patients and infections between hospitals and the community, and to nosocomial outbreaks of CA-MRSA following admission of colonized or infected patients. It is becoming increasingly difficult to distinguish between CA-MRSA and HA-MRSA on clinical and epidemiological grounds. Since HA-MRSA and CA-MRSA strains are often genotypically and phenotypically different, the microbiological characteristics of the S. aureus isolates may help distinguish between HA-MRSA and CA-MRSA infections.

Since JAMA published their finding about Invasive CA-MRSA, 11 different strains have been reported from all over the world. The latest one is Vancomycine Intermittent Resistant Strain (VISA).

Risk groups

Please Download: Chart Compare HA-MRSA with CA-MRSA

Antibiotic resistance

Although the survival tactics of bacteria contribute to antibiotic resistance, humans bear most of the responsibility for the problem. Leading causes of antibiotic resistance include:

Unnecessary antibiotic use. Like other super bugs, MRSA is the result of decades of excessive and unnecessary antibiotic use. For years, antibiotics have been prescribed for colds, flu and other viral infections that don't respond to these drugs, as well as for simple bacterial infections that normally clear on their own.

Inappropriate use of antibiotics, including not taking all of your prescription and overuse, under dose contributes to resistance. Taking antibiotics for common cold, viral infections leads to staphylococcus developing resistant strains in your body. When antibiotics were prescribed most patients did not complete the course. Sharing antibiotics with others or save unfinished antibiotics for another time is also common. Less experienced doctors, nurses and chemist prescribed lower dose that only stopped bacterial multiplication (bacteriostatic) but did not kill them (bacteriocidal).

Antibiotics in food, water and the United States, antibiotics can be found in livestock. These antibiotics find their way into municipal water systems when the runoff from feedlots contaminates streams and groundwater.

Germ mutation. Even when antibiotics are used appropriately, they contribute to the rise of drug-resistant bacteria because they don't destroy every germ they target. Bacteria live on an evolutionary fast track, so germs that survive treatment with one antibiotic soon learn to resist others. And because bacteria mutate much more quickly than new drugs can be produced, some germs end up resistant to just about everything. That's why only a handful of drugs are now effective against most forms of Staph.

Risk Factors:

Because hospital and community strains of MRSA generally occur in different settings, the risk factors for the two strains differ.
 

CA-MRSA (Community Associated MRSA)

• CA-MRSA can be particularly dangerous in children and young health adults. They often entering the body through a cut or scrape, MRSA can quickly cause a widespread infection. Children may be susceptible because their immune systems aren't fully developed or they don't yet have antibodies to common germs. Children and young adults are also much more likely to develop dangerous forms of pneumonia, which can result from CA-MRSA, than older people are. Centre

• CA-MRSA has affected sports teams, athletes and Gym. The bacteria spread easily through cuts and abrasions and skin-to-skin contact. Sharing towels or athletic equipment. CA-MRSA has spread among athletes sharing razors, towels, uniforms or equipment.

• Having a weakened immune system. People with weakened immune systems, such as those living with HIV/AIDS, are more likely to have severe CA-MRSA infections.

• Living in crowded or unsanitary conditions. Outbreaks of CA-MRSA have occurred in military training camps and in American and European prisons.

• Association with health care workers. People who are in close contact with health care workers are at increased risk of serious Staph infections.

• CA-MRSA (USA300) is also spreading through certain groups of gay men. A study published in the Annals of Internal Medicine found a new strain of MRSA spreading rapidly among gay men in Boston and San Francisco. For example, gay men in San Francisco were 13 times more likely to be infected than others in the city.

HA-MRSA (Hospital Associated-MRSA)

• A current or recent hospitalization. MRSA remains a concern in hospitals, where it can attack those most vulnerable — older adults and people with weakened immune systems, burns, surgical wounds or serious underlying health problems. This is particularly true if you have a hospital stay of more than 14 days. A 2007 report from the Association for Professionals in Infection Control and Epidemiology estimated that 46 out of every 1,000 people hospitalized are infected or colonized with MRSA.

• Living in a long term care facility increase your risk of getting infected. MRSA is also prevalent in these facilities. Carriers of MRSA have the ability to spread it, even if they're not sick themselves.

• Invasive devices used in hospitals on people like intra-venous cannula, arterial lines, catheterized, endotracheal tubes, urinary catheters, dialysis, colostomy tubes or have feeding tubes or other invasive devices are at higher risk. Injections & simple blood tests are not as safe as they used to be.

• People treated with antibiotics like fluoroquinolones (ciprofloxacin, ofloxacin or levofloxacin) or cephalosporin antibiotics can increase the risk of HA-MRSA. Under dosing and incomplete course of antibiotics increase chances of developing MRSA colonization in people treated.

When to seek medical advice:

Keep an eye on minor skin problems — pimples, insect bites (spider-bites), cuts and scrapes — especially in children. If wounds, cuts, bruised area, scratches (especially children with eczema on steroid treatment, cystic fibrosis, nephrotic syndrome on cyclophosphomides) become infected.

SYMPTOMS

Commonest MRSA clinical problems like skin and soft tissue infections (SSTIs); serious and deep seated infections presenting to GPs are often over looked. Practical advice on the isolation of MRSA is not available because the evidence base for the management of this situation is poor. The recommendations could be implemented, for example, by their integration into new or existing care pathways.

Guidelines on various aspects of the management and control of MRSA are available and are revised regularly but the doctors are not well informed.

CA-MRSA skin infections, including MRSA, generally start as small red bumps that resemble pimples, boils or spider bites. These can quickly turn into deep, painful abscesses that require surgical draining. Sometimes the bacteria remain confined to the skin. But they can also penetrate into the body, causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves and lungs.

• Redness, warmth and tenderness of the wound

• Pus — a yellowish-white fluid that may have a foul smell

• Fever (often mild)

• Ask to have any skin infection tested for MRSA before starting antibiotic therapy.

Some drugs (Fucidic acid, Bactroban, Savalon cream) that treat ordinary Staph aren't effective against MRSA, and their use could lead to serious illness and more resistant bacteria.

Doctors diagnose MRSA by checking a tissue sample or nasal secretions for signs of drug-resistant bacteria. The sample is sent to a lab where it's placed in a dish of nutrients that encourage bacterial growth (culture). But because it takes about 48 hours for the bacteria to grow, newer tests that can detect Staph DNA in a matter of hours are now becoming more widely available.

In the hospital, you may be tested for MRSA if you show signs of infection or if you are transferred into a hospital from another health care setting where MRSA is known to be present. You may also be tested if you have had a previous history of MRSA.

Both hospital- and community-associated strains of MRSA still respond to certain medications. In hospitals and care facilities, doctors often rely on the antibiotic vancomycin to treat resistant germs. CA-MRSA may be treated with vancomycin or other antibiotics that have proved effective against particular strains. Although vancomycin saves lives, it may become less effective as well. Some hospitals are already seeing strains of MRSA that are less easily killed by vancomycin.

In some cases, antibiotics may not be necessary. For example, doctors may drain a superficial abscess caused by MRSA rather than treat the infection with drugs.

Hospitals are fighting back against MRSA infection by using surveillance systems that track bacterial outbreaks and by investigating products such as antibiotic-coated catheters and gloves that release disinfectants.

Still, the best way to prevent the spread of germs is for health care workers to wash their hands frequently, to properly disinfect hospital surfaces and to take other precautions, such as wearing gowns and gloves when working with people infected with resistant bacteria.

In the hospital, people who are infected or colonized with MRSA are placed in isolation 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-washing procedures.

What you can do in the hospital

• Avoid visiting hospitals and patients unless they are closely related to you.

• Don't take your healthy family along with another sick patient to consult a doctor in ER /A&E

• Make sure you take a shower and wash your self before and after returning from hospital, walk-in clinics, or even polyclinics.

• Don't shake hands with the doctors and nurses (it's better to be rude than sick. Please read this if you want to avoid being sick  "Kissing is better than shaking hands" .

• Avoid touching equipments, computers and even TV knobs.

• Frequently wash the knobs of taps and door knobs.

• Ask all hospital staff to wash their hands using soap and water (alcohol-based hand sanitizer may be used only twice before touching you, they must wash using soap and water before and after touching you).

• Wash your own hands

Make sure that intravenous cannula and catheters are inserted under sterile conditions, for example, the person inserting them wears a gown, sterile gloves and mask and sterilizes your skin first using the right solution and for 1-2 minutes). You can also take care by washing (soap and water) the area of skin where the doctors are likely to insert cannula.

What you can do in your community

• Spread the news about CA-MRSA to other parents in your children school. Let the teachers know about the dangers of allowing child with impetigo, infected wound, child with a bad snotty nose attend classes.

• Protecting yourself from MRSA in your community-which might be just about anywhere- may seem daunting, but these common-sense precautions can help reduce your risk.

• Down-load information sheets and broachers published in our website and distribute them around in schools, your work place, sport centre, gym and any crowded place including your local pubs.

• Careful hand washing remains your best defence against germs. Scrub hands briskly for at least 15 -30 seconds (duration must be = happy birthday song), then dry them with a disposable towel and use another towel to turn off the faucet. Carry a small bottle of hand sanitizer containing at least 60 percent alcohol for times when you don't have access to soap and water.

• Avoid sharing personal items such as towels, sheets, razors, clothing and athletic equipment. MRSA spreads on contaminated objects as well as through direct contact.

• Keep cuts and abrasions clean and covered with sterile, dry bandages until they heal. The pus from infected sores may contain MRSA, and keeping wounds covered will help keep the bacteria from spreading.

• Shower after athletic games or practices. Shower immediately after each game or practice. Use soap and water. Don't share towels.

• Sit out athletic games or practices if you have a concerning infection. If you have a wound that's draining or appears infected — for example, is red, swollen, warm to the touch or tender — consider sitting out athletic games or practices until the wound has healed.

• If you have a cut or sore, wash towels and bed linens in a washing machine set to the "hot" water setting (with added bleach, if possible) and dry them in a hot dryer. Wash gym and athletic clothes after each wearing.

• If you have a skin infection that requires treatment, ask your doctor if you should be tested for MRSA.

• Doctors may prescribe drugs that aren't effective against antibiotic-resistant Staph, which delays treatment and creates more resistant germs. Testing specifically for MRSA may get you the specific antibiotic you need to effectively treat your infection.

Antibiotics and MRSA:

• Antibiotic Selection for Infections Involving Methicillin-Resistant Staphylococcus aureus

What does CA-MRSA look like?

• Digital photographs of skin infections and wounds caused by community-associated methicillin resistant Staphylococcus aureus (MRSA/Staph).

MRSA in Healthcare Settings

• Overview of MRSA in Healthcare Settings
• Fact Sheet for Healthcare Personnel
• MRSA Prevention Healthcare Guideline
• Hand Hygiene Healthcare Guideline

MRSA in the Community

• Overview of MRSA in the Community
• Information for the Public
• Information for Healthcare Providers
• Clinical Management Strategies
• Educational Materials (Posters and Information Sheet)

Other Resources

• Questions and Answers about MRSA for School Health Professionals*,
• MRSA Toolkit for Middle & High Schools
• MRSA Facts for Schools*
• Guidelines for Reducing the Spread of Staph/CAMRSA in Non-Healthcare Settings, v 2*
• Strategies for Clinical Management of MRSA in the Community: Summary of an Experts' Meeting

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