Professional Documents
Culture Documents
RISK FACTORS
contact[9]
2.2
2.4 Athletes
Locker rooms, gyms, and related athletic facilities oer
potential sites for MRSA contamination and infection.[27]
A study linked MRSA to the abrasions caused by articial turf.[28] Three studies by the Texas State Department of Health found the infection rate among football
players was 16 times the national average. In October
2006, a high-school football player was temporarily paralyzed from MRSA-infected turf burns. His infection returned in January 2007 and required three surgeries to
3
remove infected tissue, as well as three weeks of hospital stay.[29] In 2013, Lawrence Tynes, Carl Nicks, and
Johnthan Banks of the Tampa Bay Buccaneers were diagnosed with MRSA. Tynes and Nicks apparently did not
contract the infection from each other, but it is unknown
if Banks contracted it from either individual.[30] In 2015,
Los Angeles Dodgers' inelder Justin Turner was infected
while the team visited the New York Mets.[31] In October
2015, New York Giants tight end Daniel Fells was hospitalized with a serious MRSA infection.[32]
2.5
Children
Diagnosis
A selective and dierential chromogenic medium for the qualitative direct detection of MRSA.
Another common laboratory test is a rapid latex agglutination test that detects the PBP2a protein. PBP2a is a
variant penicillin-binding protein that imparts the ability
of S. aureus to be resistant to oxacillin.[40]
Diagnostic microbiology laboratories and reference laboratories are key for identifying outbreaks of MRSA. 4 Genetics
Faster techniques for identifying and characterizing
MRSA have recently been developed.[37] Normally, the Antimicrobial resistance is genetically based; resistance
bacterium must be cultured from blood, urine, sputum, is mediated by the acquisition of extrachromosomal ge-
4.1
SCCmec
4.2
mecA
GENETICS
moter and functions as a repressor.[41][43] In the presence of a -lactam antibiotic, MecR1 initiates a signal
transduction cascade that leads to transcriptional activation of mecA.[41][43] This is achieved by MecR1-mediated
cleavage of MecI, which alleviates MecI repression.[41]
mecA is further controlled by two co-repressors, BlaI
and BlaR1. blaI and blaR1 are homologous to mecI
and mecR1, respectively, and normally function as regulators of blaZ, which is responsible for penicillin
resistance.[42][47] The DNA sequences bound by MecI
and BlaI are identical;[42] therefore, BlaI can also bind
the mecA operator to repress transcription of mecA.[47]
4.4 Strains
enzyme
antibiotic
sensitive
active site
blocked
active site
4
Alanine (L or D)
D-glutamate
reactive
serine
L-lysine
working
active site
Pentaglycine chain
NAM
NAG
antibiotic
resistant
-lactam antibiotic
Acquisition of SCCmec in methicillin-sensitive staphylococcus aureus (MSSA) gives rise to a number of genetically dierent MRSA lineages. These genetic variations
within dierent MRSA strains possibly explain the variability in virulence and associated MRSA infections.[49]
The rst MRSA strain, ST250 MRSA-1 originated from
SCCmec and ST250-MSSA integration.[49] Historically,
major MRSA clones: ST2470-MRSA-I, ST239-MRSAIII, ST5-MRSA-II, and ST5-MRSA-IV were responsible for causing hospital-acquired MRSA (HA-MRSA)
infections.[49] ST239-MRSA-III, known as the Brazilian clone, was highly transmissible compared to others and distributed in Argentina, Czech Republic, and
Portugal.[49]
5
England, and the full genomic sequence of this strain
has been published.[51] EMRSA16 has been found to
be identical to the ST36:USA200 strain, which circulates in the United States, and to carry the SCCmec
type II, enterotoxin A and toxic shock syndrome toxin
1 genes.[52] Under the new international typing system,
this strain is now called MRSA252. EMRSA 15 is
also found to be one of the common MRSA strains in
Asia. Other common strains include ST5:USA100 and
EMRSA 1.[53] These strains are genetic characteristics of
HA-MRSA.[54]
5 Prevention
5.1 Screening programs
Patient screening upon hospital admission, with nasal cultures, prevents the cohabitation of MRSA carriers with
non-carriers, and exposure to infected surfaces. The
test used (whether a rapid molecular method or traditional culture) is not as important as the implementation of active screening.[66] In the United States and
Canada, the Centers for Disease Control and Prevention
issued guidelines on October 19, 2006, citing the need
for additional research, but declined to recommend such
screening.[67][68]
In some UK hospitals screening for MRSA is performed
in every patient[69] and all NHS surgical patients, except for minor surgeries, are previously checked for
MRSA.[70] There is no community screening in the UK;
however, screening of individuals is oered by some private companies.[71]
In a US cohort of 1300 healthy children, 2.4% carried
MRSA in their nose.[72]
PREVENTION
ments (Ag-A and Ag-B) exhibited any meaningful ecacy against MRSA. Stainless steel S30400 did not exhibit any antimicrobial ecacy.
In 2004, the University of Southampton research team
was the rst to clearly demonstrate that copper inhibits
MRSA.[81] On copper alloys C19700 (99% copper),
C24000 (80% copper), and C77000 (55% copper)
signicant reductions in viability were achieved at room
temperatures after 1.5 hours, 3.0 hours and 4.5 hours,
respectively. Faster antimicrobial ecacies were associated with higher copper alloy content. Stainless steel did
not exhibit any bactericidal benets.
NAV-CO2 sanitizing in Pennsylvania hospital exam room
A June 2008 report, centered on a survey by the Association for Professionals in Infection Control and Epidemiology, concluded that poor hygiene habits remain the principal barrier to signicant reductions in the spread of
MRSA.
5.3
In 2008, after evaluating a wide body of research mandated specically by the United States Environmental Used paper hospital gowns are associated with MRSA
infections, which could be avoided by proper
Protection Agency (EPA), registration approvals were hospital [85]
disposal.
granted by EPA in 2008 granting that copper alloys kill
more than 99.9% of MRSA within two hours.
Subsequent research conducted at the University of
Southampton (UK) compared the antimicrobial ecacies of copper and several non-copper proprietary coating products to kill MRSA.[79][80] At 20 C, the dropo in MRSA organisms on copper alloy C11000 is dramatic and almost complete (over 99.9% kill rate) within
75 minutes. However, neither a triclosan-based product nor two silver-containing based antimicrobial treat-
5.6 Isolation
Excluding medical facilities, current US guidance does
not require workers with MRSA infections to be routinely
excluded from the general workplace.[86] Therefore, unless directed by a health care provider, exclusion from
work should be reserved for those with wound drainage
that cannot be covered and contained with a clean, dry
5.8
bandage and for those who cannot maintain good hygiene practices.[86] Workers with active infections should
be excluded from activities where skin-to-skin contact is
likely to occur until their infections are healed. Health
care workers should follow the Centers for Disease Control and Preventions Guidelines for Infection Control in
Health Care Personnel.[87]
To prevent the spread of staph or MRSA in the workplace, employers should ensure the availability of adequate facilities and supplies that encourage workers to
practice good hygiene; that surface sanitizing in the workplace is followed; and that contaminated equipment are
sanitized with Environmental Protection Agency (EPA)registered disinfectants.[86]
5.7
5.8
7
occurred in the United States in 2002, with 99,000 associated deaths.[92] The estimated incidence is 4.5 nosocomial infections per 100 admissions, with direct costs
(at 2004 prices) ranging from $10,500 (5300, 8000
at 2006 rates) per case (for bloodstream, urinary tract,
or respiratory infections in immunocompetent patients)
to $111,000 (57,000, 85,000) per case for antibioticresistant infections in the bloodstream in patients with
transplants. With these numbers, conservative estimates
of the total direct costs of nosocomial infections are
above $17 billion. The reduction of such infections forms
an important component of eorts to improve healthcare
safety. (BMJ 2007) MRSA alone was associated with
8% of nosocomial infections reported to the CDC National Healthcare Safety Network from January 2006 to
October 2007.[93]
This problem is not unique to one country; the British National Audit Oce estimated that the incidence of nosocomial infections in Europe ranges from 4% to 10% of
all hospital admissions. As of early 2005, the number
of deaths in the United Kingdom attributed to MRSA
has been estimated by various sources to lie in the area
of 3,000 per year.[94] Staphylococcus bacteria account for
almost half of all UK hospital infections. The issue of
MRSA infections in hospitals has recently been a major
political issue in the UK, playing a signicant role in the
debates over health policy in the United Kingdom general
election held in 2005.
5.9
Decolonization
Care should be taken when trying to drain boils, as disruption of surrounding tissue can lead to larger infections, or even infection of the blood stream (often with fatal consequences).[101] Any drainage should be disposed
of very carefully. After the drainage of boils or other
treatment for MRSA, patients can shower at home using
chlorhexidine (Hibiclens) or hexachlorophene (Phisohex)
antiseptic soap (available over-the-counter at many pharmacies) from head to toe. Alternatively, a dilute bleach
bath can be taken at a concentration of 2.5 L/mL dilution of bleach (about 1/2 cup bleach per 1/4-full bathtub
of water).[102] Care should be taken to use a clean towel,
and to ensure that nasal discharge doesn't infect the towel
(see below).
All infectious lesions should be kept covered with a
dressing.[101] Mupirocin (Bactroban) 2% ointment can be
eective at reducing the size of lesions. A secondary covering of clothing is preferred.[103] As shown in an animal
study with diabetic mice, the topical application of a mixture of sugar (70%) and 3% povidone-iodine paste is an
eective agent for the treatment of diabetic ulcers with
MRSA infection.[104]
TREATMENT
diluted tea tree oil (e.g. Melaleuca). Laundry soap containing tea tree oil may be eective at decontaminating
clothing and bedding, especially if hot water and heavy
soil cycles are used, however tea tree oil may cause a rash
which MRSA can re-colonize. Alcohol-based sanitizers
can be placed near bedsides, near sitting areas, in vehicles
etc. to encourage their use.
Doctors
may
also
prescribe
antibiotics
such
as
clindamycin,
doxycycline
or
trimethoprim/sulfamethoxazole.
7.1
US and UK
9
Legend
No Data
<1%
1-5%
5 - 10 %
10 - 25 %
25 - 50 %
> 50 %
7.1
US and UK
The Oce for National Statistics reported 1,629 MRSArelated deaths in England and Wales during 2005, indicating a MRSA-related mortality rate half the rate of that in
the United States for 2005, even though the gures from
the British source were explained to be high because of
improved levels of reporting, possibly brought about by
the continued high public prole of the disease[124] during the time of the 2005 United Kingdom General Election. MRSA is thought to have caused 1,652 deaths in
2006 in UK up from 51 in 1993.[125]
It has been argued that the observed increased mortality
among MRSA-infected patients may be the result of the
increased underlying morbidity of these patients. Several studies, however, including one by Blot and colleagues, that have adjusted for underlying disease still
10
found MRSA bacteremia to have a higher attributable
mortality than methicillin-susceptible S. aureus (MSSA)
bacteremia.[126]
A population-based study of the incidence of MRSA infections in San Francisco during 200405 demonstrated
that nearly 1 in 300 residents suered from such an infection in the course of a year and that greater than
85% of these infections occurred outside of the healthcare setting.[127] A 2004 study showed that patients in
the United States with S. aureus infection had, on average, three times the length of hospital stay (14.3 vs.
4.5 days), incurred three times the total cost ($48,824
vs $14,141), and experienced ve times the risk of inhospital death (11.2% vs 2.3%) than patients without this
infection.[128] In a meta-analysis of 31 studies, Cosgrove
et al.,[129] concluded that MRSA bacteremia is associated
with increased mortality as compared with MSSA bacteremia (odds ratio = 1.93; 95% CI = 1.93 0.39).[130] In
addition, Wyllie et al. report a death rate of 34% within
30 days among patients infected with MRSA, a rate similar to the death rate of 27% seen among MSSA-infected
patients.[131]
According to the CDC, the most recent estimates of the
incidence of healthcare-associated infections that are attributable to MRSA in the United States indicate a decline in such infection rates. Incidence of MRSA central line-associated blood stream infections as reported by
hundreds of intensive care units decreased 5070% from
20012007.[122] A separate system tracking all hospital
MRSA bloodstream infections found an overall 34% decrease between 20052008.[122]
8 RESEARCH
8 Research
8.1 Clinical
Many antibiotics against MRSA are in phase II and phase
III clinical trials. e.g.:
Phase III : ceftobiprole, ceftaroline, dalbavancin,
telavancin, torezolid, iclaprim and others.
Phase II : nemonoxacin.[133]
Development of Aurograb, a treatment intended to complement antibiotics used to treat MRSA, was discontinued after showing a lack of ecacy in Phase II trials.[134]
It has been reported that maggot therapy to clean out
necrotic tissue of MRSA infection has been successful. Studies in diabetic patients reported signicantly
shorter treatment times than those achieved with standard
treatments.[135][136][137]
8.2 Pre-clinical
8.2.1 Phage therapy
An entirely dierent approach is phage therapy (e.g., at
the Eliava Institute in Georgia[138] ). Experimental phage
therapy tested in mice had a reported ecacy against up
to 95% of tested Staphylococcus isolates.[139]
11
Some semi-toxic fungi/mushrooms excrete broad
spectrum antibiotics, not all of which have been
fully identied; some have been shown to inhibit the
growth of Staphylococcus aureus.[147]
An in vitro study showed that the cannabinoids CBD
and CBG inhibit MRSA,[148] in addition to the terpenoid pinene which occurs in cannabis.[149]
Cannabinoids (components of Cannabis sativa),
including cannabidiol (CBD), cannabinol (CBN),
cannabichromene (CBC), tetrahydrocannabinol
(THC) and cannabigerol (CBG), show activity
against a variety of MRSA strains.[150]
In vitro studies have shown that oakin, an oak extract, can kill MRSA.[151]
A 1,000-year-old eye salve recipe found in the medieval Balds Leechbook at the British Library, one
of the earliest known medical textbooks, was found
to have activity against MRSA in vitro and in skin
wounds in mice.[152]
Additional images
A colourised SEM of MRSA
Scanning electron micrograph of a human neutrophil ingesting MRSA
Scanning electron micrograph of a human neutrophil ingesting MRSA
Scanning electron micrograph of a human neutrophil ingesting MRSA
10
See also
11
References
12
11
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13
14
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12 Further reading
There are several web-based resources available for further research and treatment options.
The Center for Disease Control maintains MRSA
pages that provide information surrounding the bacteria, including prevention, statistics, at risk groups,
causes, educational resources, and environmental
factors.
The National Institute for Occupational Safety and
Health maintains a webpage providing information
on the bacteria, with respect to the workplace setting, and steps towards mitigating risk from MRSA
infection.
18
The National Institutes of Health maintains Medline
Plus, a site for patients that provides information
surrounding diseases, their causes, and treatments.
Their MRSA pages provide research and information surrounding causes and treatment options.
The Mayo Clinic maintains an online site, updated
by Mayo Clinic sta, that covers the basic denition,
symptoms, and patient education for MRSA.
The online medical resource site, WebMD, maintains on MRSA that provide basic information about
the bacteria, as well as some multimedia resources
for patient education.
MRSA MD is an online medical site devoted solely
to MRSA education, treatment, and prevention.
Maintained by Dr. Kirk Bortel, MRSA MD provides treatment information and prevention education.
Maryn McKenna (2011). Superbug: The Fatal Menace of MRSA. Free Press. ISBN 978-1416557289.
12 FURTHER READING
19
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13.1
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13.2
Images
13.3
Content license