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Staph aureus are
normally found on the skin or in the nose of about one-third
of the population. They are also present in soil, animals and
have been existing in the environment for centuries. If you
have staphylococcus on your skin or in your nose but aren't
sick, you are said to be "colonized" but not infected. Healthy
people can be colonized and have no ill effects. However, they
can pass the germ to others.
Staphylococcus bacteria are generally harmless unless they
enter the body through a cut or other wound, and even then
they often cause only minor skin problems in healthy people.
However, staph infections used to cause serious illness
in older people who have weakened immune systems, usually in
hospitals and long term care facilities.
Staphylococcus aureus is the major bacterial cause of skin, soft tissue and bone infections, and one of the commonest causes of
healthcare-associated bacteraemia. About one-quarter of
healthy people carry one or more strains asymptomatically
at any given time and infections are commonly caused by
the patient’s colonizing strain.
Staph aureus acquired during exposure to hospitals and other
healthcare facilities, caused a variety of serious healthcare
associated infections. Common infections you are familiar
with are post-operative wound infections, infected cuts and bruises,
impetigo producing straw coloured secretions and pus. This was
treated with flucloxacilin / Methicilline or local antiseptic
creams.
Antibiotics
and surgical drainage are the basis of treatment of
staphylococcal infections, but the emergence of multiple
resistance to
isoxazoyl penicillin such as methicillin, oxacillin and
flucloxacillin. MRSA are cross-resistant to all currently
licensed β-lactam antibiotics. and other agents
has compromised therapy.
Symposium Index
MRSA hospitalizations have doubled since 1999, a new study
says, another indication that the drug-resistant “superbug” is
becoming an urgent public health issue. The study, which
appears in the December issue of the Journal Emerging
Infectious Diseases, is the first to examine the recent
magnitude and trends related to methicillin resistant
Staphylococcus aureus, or MRSA, infections.
MRSA is a bacterium that causes staph infections on various
parts of the body. Most often, it causes mild infections on
the skin, causing pimples or boils. But it can also lead to
more serious skin infections or infect surgical wounds,
injection sites, cuts, through IV cannula enter the
bloodstream, the lungs and also through urinary catheters.
Depending on where the MRSA infection occurs, it can be life
threatening. MRSA is difficult to treat, because it is
resistant to many common antibiotics. The Centers for Disease
Control (CDC) say MRSA infections kill about 250 people each
day. About 90,000 Americans come down with drug resistant MRSA
every year, and of that about 19,000 die from the infection.
According to this latest MRSA study, hospitalizations caused
by MRSA more than
doubled between 1999 and 2005, soaring from 127,000 to nearly
280,000. The
study concluded that MRSA and staph infections are now
“endemic, and in some
cases epidemic” in many U.S. hospitals, long-term care
facilities and communities.
The researchers who conducted the MRSA study also found that
patterns of infection have changed as well.
Traditionally, MRSA infections were problems in hospital and
other patient settings. However, in the past several
years, there has been a dramatic increase in the number of
MRSA infections acquired outside of hospital settings.
At the same time, there was no change, up or down, in the
number of deaths from hospital-associated staph or
MRSA infections. The study’s authors say this means that
antibiotic-resistant infections are spreading more rapidly
in the community while the epidemic of drug-resistant
infections in hospitals continues unabated. The end result of
this, the study authors wrote, is an increase in patient
suffering and the length of time patients spend in the
hospital
- in addition to direct health care costs, estimated to be
more than $6 billion annually.
And as MRSA infections become more frequent, in other word
giving them an opportunity to survive by introducing
them into blood stream will make them resist antibiotic
stronger and their population increases. The upsurge in
MRSA has increased demand for vancomycin, a powerful
antibiotic often used when other antibiotics fail. However,
as the use of this drug has increased, public health officials
are now reporting the deadly form of vancomycin resistant
MRSA, (VRSA) now called CA-MRSA has made the epidemic of drug
resistant staph even worse.
Invasive MRSA infection initially affected certain populations
disproportionately. It is now a major public health
problem primarily related to health care but no longer
confined to intensive care units, acute care hospitals, or any
health care institution. (JAMA. 2007;298(15):1763-1771)
What is Methicillin?
Methicillin is an antibiotic only used to test bacterial
sensitivity to flucloxacillin in laboratory. UK hospitals
reported
0.2 per 1000 occupied bed-days in 2001. Number of infections
caused by MRSA was increasing every year and has
caused 60% rise in death from staphylococcus infection in 5
years before 2001. IV Vancomycin and Teicoplanin or
local Mupirocin were used.
What’s new?
Community-associated methicillin-resistant Staphylococcus
aureus (CA-MRSA) SSTIs have become epidemic and
are now the most common type of SSTI in most outpatient
settings. Invasive CA-MRSA infections among healthy,
community-dwelling adults and children have also emerged as a
significant infectious disease. Historically, virtually
all MRSA infections had been classified as nosocomial, or
hospital-associated (HA-MRSA). In 2002, however, US
sentinel hospital data revealed that a significant number of
MRSA SSTIs-between 8% and 20%-were community associated.
CA-MRSA infections have distinct clinical, epidemiologic,
and bacterial characteristics. These
differences have significant implications for treatment,
especially in the outpatient setting.
Why is this important?
CA-MRSA infections commonly do not resolve—and may worsen—if
they are treated with traditional antibiotics.
The term CA-MRSA is used to refer to any MRSA infection with
community onset in a person without established
risk factors for HA-MRSA; these risk factors include recent
hospitalization or surgery, presence of invasive medical
devices, dialysis, or residence in a long-term care facility.
The term CA-MRSA has also been used to describe MRSA strains
with genotypes and antimicrobial susceptibility
considered typical of CA-MRSA. CA-MRSA and HA-MRSA appear to
cause similar types of infections. CA-MRSA
SSTIs can run the gamut from mild, superficial infections to
deep infections requiring hospital admission for incision
and drainage (I&D) and/or for treatment with parenteral
antibiotics.
CA-MRSA appears to be separate and distinct from HA-MRSA, with
CA-MRSA seeming to be resistant to fewer
classes and different classes of antimicrobials. Most CA-MRSA
infections are minor SSTIs, but severe invasive
disease has been reported.
Where is this happening?
CA-MRSA SSTIs are epidemic virtually everywhere and in every
community. One of the first pockets of high
prevalence was documented in 2002 in an urban California
emergency department (ED), where 61 of 79
consecutive staphylococcal SSTIs (77%) were due to CA-MRSA.
Researchers in a large Atlanta public hospital in
2003 identified 389 cases of S aureus SSTIs; 72% of these
infections were caused by CA-MRSA. In another
prospective study of 422 patients with SSTIs presenting to 11
urban EDs throughout the United States in 2004, S
aureus was isolated in 321 cases (76%); 81% of these patients
had abscesses, 11% had infected wounds, and 8%
had cellulitis. While the prevalence of CA-MRSA varied widely,
CA-MRSA was the single most common cause of
infection in 10 of 11 EDs. Populations at high risk for
CA-MRSA infection are merging. In an urban HIV clinic in
Dallas.
Toxic Staphylococcal Shock Syndrome (TSS)
The incidence of staphylococcal toxic shock syndrome (TSS) has
decreased steadily since the 1980s, when it was
first linked with use of super absorbent tampons by
menstruating women. Nonetheless, the disorder still occurs and
sometimes is overlooked as a possible cause of acute illness.
TSS now is recognized as a toxin-mediated,
multisystemic illness that strikes primarily in healthy people
of any age. It is characterized by early onset of shock
with multiorgan failure and continues to be associated with
high morbidity and mortality.
TSS was first reported by Todd and associates in 1978 in seven
children who had high fever, erythroderma,
confusion, profuse diarrhea, and shock with organ failure.
Desquamation of the skin on the palms, soles, and trunk
was noted during convalescence. Phage group I S aureus was
isolated from five of the children, and it was thought
that a new staphylococcal epidermal toxin may have been the
cause.
In 1980, Shrock observed a similar syndrome in menstruating
women and postulated that herpes infection could be
playing a role. Later that same year, another report confirmed
the association of TSS with menstruation, S aureus,
and super absorbent tampons, which were quickly withdrawn from
the market. The highest incidence of TSS was
reported in 1980 (3 to 14.4 cases per 100,000 menstruating
women per year). The greatest risk was in white
women less than 30 years of age. A novel toxin called toxic
shock syndrome toxin 1 (TSST-1) was found in more
than 90% of S aureus strains isolated from menstruating women
who had TSS.
No menstrual cases of TSS were also reported in the early
1980s and were associated with a variety of surgical
procedures (eg, rhinoplasty, nasal packing, and postpartum
procedures) and medical conditions (eg, pneumonia,
influenza, infection). Nonetheless, the incidence of TSS
decreased significantly after hyper absorbable tampons
were removed from the market and federal regulations for
tampons were put in place. Currently, the number of
cases of menstrual TSS is estimated to be about 1/100,000, and
the case-fatality ratio is 3.3% (compared with 5.6%
initially). The incidence of no menstrual TSS now exceeds that
of menstrual TSS. A review of surveillance data for
1979 through 1996 confirmed the decline in the incidence of
TSS and the increase in the proportion of no menstrual
cases.
Clinical presentation
On menstrual TSS is seen more often nowadays than menstrual
TSS. The nonmenstrual form is observed in a
variety of medical and surgical conditions, mainly in surgical
wound infection with S aureus, postpartum infections,
and rhinoplasty in which stents or nasal packing is used.
Among the nonsurgical focal infections associated with
TSS are cellulitis, subcutaneous abscesses, infected burns,
suppurative hidradenitis, bursitis, and pneumonia with
or without an antecedent influenza infection.
Predisposing factors include nasal packing, influenza
infection, and prior use of antibiotics, nonsteroidal
antiinflammatory
drugs (NSAIDs), or barrier contraceptives. Postsurgical TSS
usually occurs 2 days after the procedure
and is associated with a benign-appearing wound in 40% of
cases. It is crucial to suspect TSS in these
circumstances and to obtain cultures from the wound. Delay in
recognizing the early signs of TSS is associated with
increased morbidity and mortality.
Malaise, myalgia, diarrhea, and chills often precede the onset
of the other physical manifestations of staphylococcal
TSS. Fever, confusion, and lethargy develop soon after the
prodromal syndrome, which is associated with
symptoms of hypovolaemia (eg, palpitations, light-headedness,
orthostatic) related to capillary leakage and
diarrhea. Fever, hyperventilation, hypotension, tachycardia,
and erythematous rash are often evident on physical
examination. The rash is described as diffuse macular
erythroderma that is confluent or scarlatiniform in most of
the
cases but also could be patchy in distribution.
Other signs include strawberry tongue, conjunctival hyperemia,
and erythema and edema of palms and soles.
Hematological, hepatic, muscular, renal, gastrointestinal, and
central nervous system involvement is common.
Desquamation usually occurs 1 to 2 weeks
after the onset of illness. In nonmenstrual TSS,
classic signs of localized infection at the surgical site may
be absent, which makes clinical diagnosis challenging.
Complications of TSS include acute renal failure, adult
respiratory distress syndrome, disseminated intravascular
coagulation, electrolyte disturbances (hypocalcaemia,
hypophosphataemia, and hypomagnesaemia),
cardiomyopathy, encephalopathy, and hair and nail loss.
Nonmenstrual TSS is associated with more renal and
nervous system complications than menstrual TSS. In addition,
the case-fatality rate is higher with the nonmenstrual
form of the disorder, possibly because of delay in making the
appropriate diagnosis.
When TSS is treated appropriately, full recovery is the rule,
although some patients may have persistent
neuropsychological dysfunction (eg, memory loss, lack of
concentration), mild renal failure, late-onset rash, or onset
of new allergies. For epidemiologic purposes, a clinical case
definition of TSS was developed by the Centers for
Disease Control and Prevention in 1980, and it still plays an
important role in diagnosis (table 1). However, milder
cases of TSS that do not fulfill all the criteria certainly
are likely to occur.
Case definition of staphylococcal toxic shock syndrome
developed by the CDC and Prevention
Major criteria (all 4 must be met)
-
Fever: temperature >38.9°C (102°F)
-
Rash: diffuse macular erythroderma
-
Desquamation: 1 to 2 wk after onset of illness, particularly
of palms and soles
-
Hypotension: systolic blood pressure <90 mm Hg for adults or
<5th percentile by age for children <16 yr of age, or
orthostatic syncope
-
Multisystem involvement (3 or more must be met)
-
Gastrointestinal: vomiting or diarrhea at onset of illness
-
Muscular: severe myalgia or creatine kinase level twice upper
limit of normal for laboratory
-
Mucous membrane: vaginal, oropharyngeal, or conjunctival
hyperemia
-
Renal: blood urea nitrogen or creatinine level at least twice
upper limit of normal for laboratory, or >5 white blood
cells per high-power field in absence of urinary tract
infection
-
Hepatic: total bilirubin, aspartate aminotransferase, or
alanine aminotransferase at least twice upper limit of normal
for laboratory
-
Hematological: platelets <100,000/mm3
-
Central nervous system: disorientation or alterations in
consciousness without focal neurologic signs when fever and
hypotension are absent
Normal results on the following tests
-
Blood, throat, or cerebrospinal fluid cultures (blood culture
may be positive for S aureus)
-
Rise in titer in antibody tests for Rocky Mountain spotted
fever, leptospirosis, or measles
Adapted from Greenman RL, Immerman RP. Toxic shock syndrome:
what have we learned? Postgrad Med
1987;81(4):147-60.
How Did We Get To This Stage?
In 1980s MRSA infections were reported from various pediatric
departments in UK hospitals. During this period, HIV
was also becoming a major problem and attracted media
attention. Staphylococcus was not seen as a major threat
by doctors and often dismissed blood culture results as normal
commensal. Some babies were very ill and so were
treated with vancomycin. These babies should have been treated
in isolation but the guidelines were not strictly
followed.
We initially noticed an increased infection rate in babies who
were very ill, very preterm or when multiple punctures
to introduce cannula or catheters. After lengthy discussion
with our seniors about the association of higher infection
rate in babies and multiple punctures due to difficult to
cannulate, we could not organize a study to prove our
hypothesis. We decided to identify reasons we fail to
cannulate in the first attempt, and hoped we could reduce the
number of attempts. After studying the video recordings and
close observation we identified two important mistakes
resulting in failure rate. The operator was either moving the
needle forward (double puncture) or withdrawing (premature
withdrawal) prior to cannula entering the lumen of blood
vessels.
We constructed the first cannula introducing device to help
ease the forward movement of cannula to reduce double
puncture. We managed to get permission to tryout our cannula
introducing technique in babies. We were allowed to
try the cannula introducer only after SHO & Registrar failed
to cannulate. We could not prove our hypothesis about
infection rate as the babies were subjected to multiple
attempts prior to me trying my cannula introducer.
The results of this study were published and the video
recording of the technique was presented to cannula
manufacturers. We had hoped the cannula manufacturers will
understand and help produce spring-loaded cannula
to test the hypothesis and prove the device will reduce the
number of attempts to cannulate and result in reducing
the rate of spreading MRSA infection in hospital. The cannula
company was initially keen to produce the spring
loaded cannula decided to abandon the project due to fear of
de-skilling doctors and nurses. They invested large
amount of their R&D funds to bring in Safety cannula that only
offer safety features to protect staff from needle stick
injury and not cater to patient’s safety.
Various hospitals started using nurses as phlebotomy and
cannula introducing technicians. These nurses were
trained and have resulted in doctors not often getting an
opportunity to introduce cannula. Nursing Association (UK)
published paper recommending their member to pass on the
responsibility to cannulate in emergency situation and
if the patient is said to be critical or the nurse felt the
technique will be difficult.
TRANSMISSION:
Staph is spread by contact MRSA is transmitted by touching
someone who is carrying the bacteria, or by touching
something they have touched. According to the Centers for
Disease Control (CDC) the most common ways to
spread MRSA are:
-
Close skin-to-skin contact
-
Openings in the skin, like cuts or abrasions
-
Crowded living conditions, like in hospitals or prisons
-
Poor hygiene
In health care centers people infected with MRSA are often
kept separate from other patients to reduce the risk of
the bacteria spreading.
PREVENTION:
There are several preventative measures that can be taken to
stop the spread of MRSA. The CDC recommends:
-
Wash your hands with soap for as long as it takes you to
recite the alphabet. When washing hands isn’t
possible, use alcohol based hand sanitizer.
-
Cover all cuts and scrapes with a clean bandage.
-
Don’t ever touch another person’s wounds or bandages.
-
Don’t share personal items like towels or razors?
-
Dry clothes, sheets and towels in a dryer rather than
hanging them out to dry.
Flu or common cold is common during the winter months but it’s
really not a
big threat. CA-MRSA will be a major problem in children with
runny nose
because the often develop dryness and soreness around their
nostrils due to
repeated claming using dry paper towels. Nose and the hands
are said to be
colonized with CA-MRSA and so likely infected cuts and cracked
skin around
the nose.
As children, are told to cover our mouths and noses when we
cough and
sneeze. This puts the CA-MRSA into their hands. Then when they
touch
things: papers, doorknobs or other people’s hands. By touching
noses or eyes
they put the bacteria right where they can begin to cause
infection. Eyes are
connected to our noses by a duct that drains tears so touching
our eyes is a
risk and rapid spread of infection to eyes.
Hand Washing
To be effective, hands should be rubbed together vigorously
with soap and warm water for at least 15 - 30 seconds.
Brief rubbing or simply rinsing under running water is not
enough. Contaminants are stuck in oils that adhere to the
skin. Agitation by rubbing loosens the dead skin cells, and
soap keeps the contaminants and germs suspended in
the water so they rinse off. Soap does not kill the bacteria.
In fact, germicidal soaps must remain in contact with the
skin for several minutes to kill germs. Anti-bacterial soaps
may give a false sense of security that could lead to less
vigorous washing.
This technique also removes bacteria and viruses that can
cause intestinal diseases. Cruise lines have made the
news in recent times when large numbers of passengers have
been sickened by infectious diarrhea and vomiting.
Hepatitis A can be passed on by food handlers at home or in
restaurants. Even bacteria from raw meat can be
spread to others without proper hand washing.
Methicillin-resistant Staphylococcus aureus (MRSA) infections
have made the news due to some deaths from the
bacterium. While the existence of the bacteria is partly due
to the widespread use of antibiotics, the organism is no
more infectious than others people can have on their skin or
in their noses. It’s just harder to eliminate once an
infection is present. Preventing infection is the first line
of defense against hard to treat infections. Medical
personnel must be the leaders in this movement to reduce
infections cleaning or sanitizing hands before and after
each patient encounter.
If washing with soap is not an option, alcohol gel sanitizers
are a good option. These alcohol-based sanitizers have
been shown to kill pathologic bacteria in seconds. They can be
kept close at hand to eliminate walking to a sink.
With their introduction, non-medical people also may benefit.
Research has shown significant reductions in illness in
schools where hand sanitizers have been used because they can
be kept in the classroom so sinks are not needed.
Visible dirt should still be removed by washing, but hand
sanitizers can eliminate germs that cause colds and other
illnesses.
The bacterial elimination effort can be carried a bit too far,
though. Some scientists believe that our immune
systems learn to distinguish bad germs from good germs by
being exposed to dirt and bacteria early in life. Studies
are ongoing, but many doctors think that excessively clean
environments may not be a good idea. It may not be
necessary to maintain a completely antiseptic environment for
children, but teaching children to wash their hands
before eating and after using the bathroom is important.
Skin Antisepsis
Skin cleansing and antisepsis of the insertion site is
considered one of the most important measures for
Preventing infections associated with vascular access devices
(Evidence-Based Practice in Infection Control
(EPIC), 2001a, 2001b; LeBlanc & Cobbett, 2000; Pearson, 1996a,
1996b). Skin must be clean; that is, free of soil,
dust, and organic material prior to applying the antiseptic
(CDC, 2002; Health Canada, 2003). Organisms
responsible for catheter-related infections originate mainly
from the client’s own skin flora (Crow, 1996; Jackson,
2001; RCN, 2003) or from the hands of the health care
professional inserting or handling the device (Hadaway,
2003b; Jackson, 2001). These organisms can be introduced along
with the catheter or can gain access while the
catheter is in place. Catheter movement in or out of the
insertion site (known as “pistoning”) can also allow for skin
organisms to migrate into the tract and potentially cause
infections (Hadaway, 2003b).
Disinfect clean skin with an appropriate antiseptic before
catheter insertion and with each dressing change. The
antiseptic solution must be compatible with the catheter
material (Hadaway, 2003a). Acetone products should be
avoided as they may cause irritation and affect the integrity
of the catheter (O’Grady, et al., 2002; Pearson, 1996a,
1996b) and alcohol-based solutions are not recommended for
certain devices.
Studies have shown that 2% chlorhexidine gluconate solution
significantly lowers catheter-related
Bloodstream infection rates when compared with 10% povidone-iodine
and 70% isopropyl alcohol (LeBlanc &
Cobbett, 2000; Maki, Ringer & Alvarado, 1991; Mimoz, et al.,
1996; Rosenthal, 2003; Zitella, 2004). Chlorhexidine
gluconate offers a broad spectrum of antimicrobial activity
and long-term microbacteriocidal action after application
(Hadaway, 2003a). Antiseptics should remain on the insertion
site and be allowed to air dry before catheter insertion
and/or dressing change. Table 1 describes the required drying
time needed for particular solutions in order to
prevent skin breakdown as a result of chemical reaction
between the solution and the dressing.
Drying Times
Client tolerance and preference may influence the use of
antiseptic solutions. Where alternative antiseptic solutions
are not indicated in a procedure, the nurse should consult the
appropriate health care practitioner to determine the
best solution for the client.
Antiseptic Cleaning Solutions Drying Time
-
Chlorhexidine gluconate 2% with Alcohol 30 seconds – 1 minute
-
Chlorhexidine gluconate without Alcohol 2 minutes
-
Poviodine-Iodine 2 minutes
-
Isopropyl Alcohol 70% Kills bacteria only when applied
Dries quickly, No lasting Bactericidal effect
Vaccination
Genetically engineered vaccine has been shown to protect
against life-threatening Staphylococcus aureus
infections, a major risk among hospitalized patients. In a
recent interview, Henry Shinefield, MD, co director of the
Kaiser Permanente Vaccine Study Center in Oakland, California,
stated that "the potential for this vaccine is very
exciting. It could well be a major breakthrough in protecting
patients from these serious infections."
Among patients receiving the vaccine, S aureus antibody levels
peaked at 10 to 14 days, plateau until about 40
weeks, and then dropped to baseline as the vaccine lost its
effectiveness. At 40 weeks, 26 patients in the placebo
group had had S aureus infections, compared with 11 in the
vaccine group. This represented a 57% reduction in the
infection rate and was considered statistically significant.
"These patients were at very high risk," Dr Shinefield pointed
out. "The fact that the vaccine prevents infection,
rather than stopping it after it starts, offers new avenues
for prophylaxis in many high-risk situations. This is
especially important because of increasing resistance of
bacteria to antibiotics."
The vaccine was created at the National Institutes of Health
and is one of several S aureus vaccines in
development. None of the other products have reached the
advanced clinical trial stage at this time.
How Can Our Contribution Help?
We have organized trial, observation study of this very
important life saving most common minor surgical procedure
performed in hospitals. In UK the 16 million cannula were used
last year. On average, doctors take 3 attempts to
introduce a cannula in patients. The figures published claim
60% success but do not show the number of attempts
taken.
Our hypothesis to reduce number of patients contracting MRSA
in hospitals is because the cannula needle is
inserted without adequate care of skin preparation. Multiple
punctures reduce care of skin preparation and increase
chances of infection.
We hope the two devices we designed to reduce the time taken,
attempts, discarded waste and needle tip
protection will be available for us to conduct further
investigation. This change in technique will improve
successful
rate and reduce the spread of MRSA.
The annual cost in the US to treat hospitalized patients with
methicillin resistant Staphylococcus aureus (MRSA)
infections is estimated to be $3.2 billion to $4.2 billion,
according to a new analysis presented at the annual meeting
of the "International Society for Pharmacoeconomics and
Outcomes Research" (ISPOR) in Washington, D.C.
Prolonged hospital stays, including time spent in intensive
care units, primarily drive the high costs of treating
infections caused by MRSA, a serious, multi-drug resistant
pathogen.
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