Because of the increasing incidence of CA-MRSA in student athletes in
Mecklenburg County, North Carolina over the past two years, the Health
Communications staff of the Mecklenburg County Health Department produced
a 7-minute DVD, ÿffff93Preventing MRSA in the Athletic Setting,ÿffff94
which targets student athletes with prevention messages. The Charlotte-Mecklenburg
School System collaborated with our staff in the planning and distribution
of the video.
While we have no way of scientifically tracking the incidence of CA-MRSA
in our community, anecdotal conversations with primary care physicians
and laboratorians, and a decrease in telephone calls to school nurses
suggest that the measures recommended by the CDC and highlighted in the
recent Public Health Grand Rounds on CA-MRSA appear beneficial.
The video and other educational materials are available at the Public
Health Grand Rounds website. Please let us know if you have any questions
about these materials or about prevention efforts in our community.
FYI only. I attached a report to our local health care providers regarding
results for surveillance of CA-MRSA. This report was well received
by our local health care providers including ID physicians as well
as out of state physicians, nurses, and other clinicians. Thanks.
Attachment: Surveillance.pdf
Our local health department once received a report of a cluster of
3 MRSA skin infection among three wrestlers associated with a tournament
held by a regional wrestling association. We followed the NCAA's guidelines
to recommend wrestling association to screen every participant for possible
MRSA skin infections prior to subsequent tournaments. What are CDC's
recommendation? Would you please comment on the role of local health
department in such screening activities? Are we supposed to provide any
resources to assist screening?
CDC's recommendations for preventing staphylococcal skin infections among sports participants are described in MMWR (" Methicillin-Resistant Staphylococcus aureus Infections Among Competitive Sports Participants --- Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000--2003" , August 22, 2003 / 52(33);793-795, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5233a4.htm), and include training athletes and coaches in first aid for wounds and recognition of wounds that are potentially infected, encouraging athletes to report skin lesions to coaches and encourage coaches to assess athletes regularly for skin lesions, and several other recommendations. Health departments do not necessarily need to be actively involved in these preventive screening activities (although they may wish to provide educational materials to the athletes and coaches).
Subject: ca-MRSA Necrotizing Pneumonia Are the risk factors for pulmonary infections different from those
for skin infections?
The risk factors for pneumonia are not fully determined and are likely
to differ from those for skin infection, although there may be some in
common. Recent surveillance has found CA-MRSA pneumonia in persons with
a preceding viral respiratory ilness or influenza-like illness.
Hageman J, Francis J, Uyeki T, et al. Emergence of Methicillin-Resistant
Staphylococcus aureus as a Cause of Community-Acquired Pneumonia During
the Influenza Season, 2003-04 [Abstract Latebreaker #8]. In: Program
and abstracts of the 42nd Annual Meeting of the Infectious Diseases Society
of America (Boston, MA). Alexandria, VA: Infectious Diseases Society
of America, 2004.
Francis JS, Doherty MC, Lopatin U, Johnston CP, Sinha G, Ross T, Cai
M, Hansel NN, Perl T, Ticehurst JR, Carroll K, Thomas DL, Nuermberger
E, Bartlett JG. Severe community-onset pneumonia in healthy adults caused
by methicillin-resistant Staphylococcus aureus carrying the Panton-Valentine
leukocidin genes. Clin Infect Dis. 2005 Jan 1;40(1):100-7
Any data on MRSA transmission in utero?
If the mother has a history of MRSA in an abdominal wound during the
pregnancy but at the time of delivery there are no wounds or signs of
infection, what are the risks of transmission to the newborn?
I am unaward of data on risk of transmission to the newborn in this
situation. Case reports of early onset sepsis with MRSA (suggesting transmission
in utero or during delivery) are rare. There are no data that I am aware
of to suggest that in the example you pose that the woman or her newborn
should be treated prophylactically in any way, or that contact between
the mother and her baby should be restricted after birth. In terms of
contact precautions during delivery, the hospital should follow their
routine policy for patients with known previous MRSA infection or colonization.
At discharge, the mother should be instructed to reognize early signs
of skin infection abscess in infant and to seek care if any symptoms
occur (and to notify provider that she has a history of MRSA infection).
Does anyone understand why MSM's are at a higher risk for MRSA?
It is not known that MSM are at higher risk. To date, reports have been received of CA-MRSA infection in MSM, but not as a part of an epidemiological study that would indicate higher risk or risk factors.
Subject: CA-MRSA.How would you be able to tell the differnce between the CA-MRSA and
hospital MRSA in a laboratory without having any clinical information.
Can one look at a culture and sensitivity and predict that this is a
possible CA-MRSA?
Thank you.
Laboratory testing differences between typical Community-associated
MRSA and Healthcare-associated MRSA include:
CA-MRSA is usually susceptible to chloramphenicol, clindamycin and variably
resistant (there is geographica variability) to fluoroquinolones; HA-MRSA
is usually resistant to all of these drugs. CA-MRSA will usually contain
a resistance carrying element referred to as SCCmec IV; HA-MRSA will
typically have SCCmec II. Finally, CA-MRSA commonly contains genes for
Panton-Valentine leukocidin and HA-MRSA does not. Except for the susceptibility
testing, these are not routine tests. Please note, a finding of susceptibility
does not necessarily make the drug an appropriate treatment choice.
Is there protocol for testing/treating pets, horse, etc. of a patient
known to have MRSA?
Thanks
Animals can be infected with staphylococcus. Research is being conducted to determine the specific risks and treatment protocols regarding transmission between animals and humans.
Subject: nasal carriage of CA-MRSA I'm curious to know if individuals seen with CA-MRSA skin infections
are cultured for nasal carriage of the same organism and if most are
colonized?
If most of those with infections are also nasally colonized, should we
be concerned about individuals who are admitted to in-patient facilities
with nasal MRSA carriage, who have no current infection? Should we assume
the patient may be at increased risk of infection with the virulent strain
of CA-MRSA, especially in those who have MRSA in nares and have no recent
exposure to antibiotics or health care settings?
Only a small percentage of persons who carry any form of staph on their
skin or in their nares subsequently develop disease within a short period
of time. Because many people at any given time may be staph carriers,
decolonization outside of the context of ongoing illness or increased
transmission is unlikely to be useful for preventing disease. In addition,
the overuse of decolonization antimicrobials poses the risk of creating
accelerating the development of resistance to these drugs.
What are your feelings regarding maintaining an ongoing surveilallance
program of the CA-MRSA that we have identified within the jail. I have
been actively monitoring and tracking all the MRSA infections in the
jail since 2002 and worked with the Seattle King County Public Health
Epidemiology Department in data gathering, which assisted in the identification
of CA-MRSA within our correctional health system. I have not been able
to identify any trends related to spread within the jail, we of course
have the " seasonal" increases and decreases of CA-MRSA in the numbers
of cases we have, do you feel it is worth while to continue to track
each patient identified with CA-MRSA, monitor antibiotic use as well
as other course of treatment(s)used to resolve the abscesses/wounds?
The decision to conduct surveillance in a given setting depends on the institution, the interest by the local health department, and other factors such as available interventions. Correctional Facilities have demonstrated a high risk for transmission of CA-MRSA and conducting surveillance in this setting is reasonable to determine if recommended control measures remain effective and for early detection of outbreaks.
Subject: D test for inducible Clindamycin resistance Do you suggest routinely doing the D-test on all MRSA isolates?
Reference on methods:
Fiebelkorn, K. R., S. A. Crawford, M. L. McElmeel, and J. H. Jorgensen.
2003. Practical disk diffusion method for detection of inducible clindamycin
resistance in Staphylococcus aureus and coagulase-negative staphylococci.
J. Clin. Microbiol. 41:4740-4744.
The D-test should be done on all MRSA isolates that are erythromycin
resistant and clindamycin susceptible on initial screening. If the laboratory
does not have capacity to do the D-test, clindamycin susceptibility should
be reported as indeterminate if isolate is erythromycin-resistant.
Based on our local surveillance data for CA-MRSA, we highly recommend
D test for those isolates with resistant to erythromycin. One major local
hospital in our community always run D test regardless of physician's
request.
If a patient is known to be MRSA positive and no follow up cultures
have been done for tested treatment would the use of gowns be recommended
for all direct patient care with this type of client in a home care setting?
Household members do not need to practice special infection control
precautions during contact with an MRSA-colonized patient in the home
setting who does not have active infection. However, standard household
hygiene principles should be practiced (e.g., hand hygiene, no sharing
of personal items, etc).
Policies for home healthcare personnel who may be treating the MRSA colonized
patient in the home have varied widely. Some agencies practice contact
precautions, including gown and gloves, when in direct contact with these
patients. Others have advocated modified contact precautions (e.g., gloves
only), while still others have chosen standard precautions in this setting.
The decision should be made in part based upon the nature of the patient
population. If a home healthcare practitioner will be visiting multiple
patients on a given day, and there are number of patients who are at
high risk for infection (e.g., immunocompromised, invasive lines, etc.),
a more aggressive infection control approach might be reasonable. There
may be other practical issues that factor into the decision as well.
If possible, it might also make some sense to temporally " cohort" known
colonized patients until the end of the day, that is visiting patients
not known to be colonized first, and MRSA colonized patients last.
With MRSA positive patients, washing the hands is the most important
precaution. If the patient has a wound, we want our staff to gown and
use an eye shield PRN, for example if the wound is on the patient's heel
and it is being irrigated. [In that case, irrigant from the wound can
splash on the nurse's face.]
The patient's family should use good hand hygiene, be sure to not share
towels and linens, and carefully handle soiled linens, diapers, etc.
The patient's bathroom should be disinfected regularly, especially if
the tub or sink is shared with others.
We ask our nurses to apply hand hygiene after leaving the home, because
they may be visiting other patients that day.
That should help prevent the hands from spreading the MRSA to patients
seen later that day.
What, again, where the drugs of choice to treat CA-MRSA?
The most important treatment for CA-MRSA skin and soft tissue infections
is drainage of any collection of pus. A sample should be sent to the
microbiology laboratory for susceptibility testing. If drug treatment
is thought to be necessary, empiric therapy with antimicrobials until
microbiology laboratory results are available should be guided by local
susceptibility patterns, which are known to the microbiology laboratory
and infectious disease specialists. These will differ in different parts
of the country.
What is the recommended LENGTH of treatment? Sounded like the DOC is
septra DS +/- rifampin or clindamycin.
Based on our experience in conducting CA-MRSA surveillance in the local
level, we agree with Rx recommendations in Seattle's interim guideline.
If Abx is really necessary, we (local health department and local ID
physicians) recommend to add an effective abx such as Clindamycin, Bactrim
until susceptibility results are back.
when will this be archive to get to watch it again or to get handouts
to down load?
The webcast and handouts are available now. Follow the links from our
home page. After a few weeks, these links are moved to archived programs,
but will still be available.
Does the fact adolescents are put on oral antibiotics for acne have
any relationship with the development of CA-MRSA?
I am unaware on the individual patient level whether use of antibiotics for acne increases risk for subsequent CA-MRSA infection. Antimicrobial use in general, among everyone, creates the milieu in which mutations confering resistance are provided a selective advantage and more likely to spread. For that reason, CDC and others encourage appropriate use, reducing the use of antimicrobials in situations where they are clearly unnecessary (e.g., antibacterial drugs for a viral infection).
Subject: Welcome!Welcome to the Discussion Forum for the Public Health Grand Rounds program
Antimicrobial Resistance: Old bugs, New Threats and the Public Health
Response. Online discussion will be facilitated by content experts from
the Centers for Disease Control and Prevention (CDC) beginning April
8 and ending April 15. During that time, we invite you to share your
experiences, comment on issues raised in the program, and pose questions
to the panelists, CDC experts, and forum participants. Thank you for
your participation.