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Methicillin-resistant Staphylococcus Aureus (MRSA) in Institutional Settings

There are serious outbreaks of MRSA in several AFSCME institutions. MRSA is difficult to treat and can cause potentially life-threatening complications. Controlling transmission requires strict adherence to infection control procedures.

Introduction

Staphylococcus aureus or "staph" bacteria are generally found on the skin or in the nose in about one third of the population. MRSA is a strain of staph bacteria that has become resistant to broad spectrum antibiotics, and therefore difficult to treat. Healthy people can carry staph and never get sick; but they can pass the bacteria to others. Staph bacteria are generally harmless unless they enter the body through a cut or wound. They survive well in the environment, and have to be killed on surfaces with disinfectant.

MRSA is spread by contact. A person can get MRSA by direct contact with infected individual or by touching objects that have the bacteria on them through a cut, scrape or wound, or in the eyes or mouth.

Until recently, MRSA outbreaks were confined to hospital settings. In the 1990's a new type of MRSA began to show up in the wider community. That form of staph is known as community-associated MRSA or CA-MRSA. MRSA is responsible for many serious skin and soft tissue infections and a serious type of pneumonia. When not treated properly, MRSA can be fatal.

Who is at Risk

Many people come into contact with MRSA and show few or no symptoms. However, those with suppressed immune systems (e.g. from HIV/AIDs, TB, recent surgery, bone marrow transplant, chemo and other therapies) are at high risk. So too are the elderly, the very young and those who are ill. Since MRSA is spread by contact, people who work in close proximity with these individuals, such as direct care personnel, nursing home workers and correctional officers, are also at risk. Person to person transmission in institutional settings, usually via the hands, has been a major factor in the increase in MRSA cases.

Signs and Symptoms

Pimples, rashes or pus-filled boils, especially when warm, painful, red or swollen, can indicate a staph infection. Staph, including MRSA, can cause complications at surgical sites and around catheters, feeding tubes and other invasive devices. This can lead to high fever, blood infections and pneumonia.

Staph is confirmed by lab analysis of a swab sample. A swab can be taken from inside the nose or from a draining sore. If the infection is determined to be staph, a second test is usually done to determine if it is MRSA.

Treatment, Prevention and Controls

Most staph infections are treated with good wound care: keeping the wound clean, dry and covered. Abscesses may be drained, treated and covered. However, if the body cannot fight the infection on its own, Vancomycin is one of the few antibiotics that is still effective in treating strains of MRSA.

The best way to fight MRSA is to prevent its growth on surfaces and prevent contact with infected individuals. This includes regular cleaning and disinfection of surfaces, such as toileting and shower areas, fitness equipment, tables and cafeteria equipment. Frequent hand washing and the use of alcohol-based hand sanitizers have been shown to be effective in controlling the spread of MRSA. Standard precautions should always be followed. Workers should take care to protect their own skin, and cover any open sores or wounds.

What Are Standard Precautions?

Standard Precautions refer to the infection control practice of treating all patients' blood, body fluids, secretions, excretions (except sweat), non-intact skin and mucous membranes as infectious. Standard Precautions include hand hygiene and, depending on the anticipated exposure, use of a barrier (gloves, gown, mask, eye protection or face shield) between persons. Equipment or items in a patient's environment that was likely contaminated must be handled in a way to prevent disease transmission.

The Center for Disease Control - Prevention (DCD) recommends the following control measures for Hospitals, Mental Health and Developmental Disabilities, and Long Term Care Facilities

  • Screen all incoming at-risk patients/residents. Implement systems to communicate with local health departments.
  • Consistently use standard precautions. Wash hands before and after contact with patients/residents, whether gloves are worn or not. Use hand-sanitizing gels when hand washing is not possible.
  • Use contact precautions for all colonized and at risk patients/residents. Change gloves between each patient.
  • Insert and remove all catheters and intravenous tubes under sterile conditions.
  • Regularly clean and disinfect all hard surfaces, including toileting and shower areas, bed rails, stretchers, wheelchairs, portable diagnostic equipment, restraining devices, eating surfaces, door knobs, etc., with an EPA-approved germicide known to kill staph. Generally, disinfectant should be left on the surfaces for at least 10 minutes.
  • Isolate patients/residents diagnosed with MRSA pneumonia. Patients or residents with open or draining abscesses should also be placed in a private room or placed with other residents and patients similarly diagnosed.
  • Verify that patients/residents complete all medications.
  • Identify patients who are unable to assist in their own hygiene(or uncooperative). Include this in treatment and housekeeping protocols.
  • Educate all staff-including housekeeping, dietary and custodial.

The Federal Bureau of Prisons recommends the following control measures for Correctional Facilities

  • Wash hands before and after contact with inmates whether gloves are worn or not. Use hand-sanitizing gel or disposable anti-microbial wipe if soap and water are not available.
  • Wear gloves during pat downs. When open skin contact is likely, change gloves between inmates.
  • Use barrier protections (gloves, eye protection, gowns) when contact with blood, body fluids and wound drainage is anticipated.
  • Launder sheets, towels, uniforms and underclothing at high temperatures (at least 160 degrees) and dry on the hottest setting or use a detergent proven to kill staph.
  • Regularly clean and disinfect hard surfaces and high traffic areas such as shower facilities, toilets, toileting areas and fitness equipment, before and after use. Disinfectant must be on surfaces for at least 10 minutes.
  • Disinfect restraining devices (e.g. handcuffs).
  • Place inmates diagnosed with MRSA pneumonia in isolation. Inmates with extensive draining lesions (keep covered) should either be isolated or placed with other inmates with similar diagnoses. Negative pressure rooms are not required.
  • Do not share any personal items, such as razors, towels or combs.
  • Treat wound dressing as medical waste never place in general trash.
  • Do not transfer inmates with contagious MRSA. It is recommended that a screening protocol be put in place for all incoming persons.
  • Maintain a log of all skin lesions and infections. Outbreaks of MRSA must be reported to local public health officials.
  • Provide extensive inmate education.

Various sources recommend the following control measures for Community Areas (schools, day care centers, recreation centers)

  • Routinely clean and disinfect all hard surfaces. Leave the disinfectant on the surface for at least 10 minutes.
  • Maintain an adequate supply of soap. Aggressive hand washing and/or the use of alcohol-based hand sanitizers is one of the best ways to control staph.
  • Persons using or working in the facility must keep all open wounds covered.

Resistant strains of bacteria, including staph, will continue to evolve as long as unnecessary use of antibiotics continues. Antibiotics are used in agriculture in pig, chicken and cattle feed. Patients often do not finish their prescriptions, which contributes to antibiotic resistance. New drugs take years to develop, and bacteria can mutate and change at an alarming rate. Attention to hygiene and infection control will continue to be the most effective methods for dealing with these types of infections.

References

Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006.
http://www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf

Centers for Disease Control and Prevention. Methicillin-Resistant Staphylococcus aureus Infections in Correctional Facilities --- Georgia, California, and Texas, 2001-2003. MMWR2003; 52(41);992-996
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5241a4.htm

Federal Bureau of Prisons. Management of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections, Clinical Practice Guidelines, August, 2005.
http://www.bop.gov//news/PDFs/mrsa.pdf

Fleming, J. Environmental Surface Disinfection: Meeting Best Practices for Infection Prevention. Infection Control Today, June 2007. 
http://www.infectioncontroltoday.com/articles/761feat2.html

Mayo Clinic. MRSA Infection. July 3, 2007.
http://www.mayoclinic.com/health/mrsa/DS00735

Research and Collective Bargaining Services
August 2007

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