Community Acquired Methicillin Resistant Staph aureus (CAMRSA

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Community-Acquired Methicillin- Resistant Staph aureus (CAMRSA): What You Need to Know Helene M. Calvet, MD

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What is Staphylococcus aureus? Staphylococcus aureus (“staph”) is a bacteria Can live on skin or other parts of the body and NOT cause disease (called colonization) or can invade and cause infections Staph that is resistant to all medications in the penicillin group is called “methicillin-resistant staph aureus” (or “MRSA”) MRSA is also resistant to a group of penicillin-related medications called cephalosporins MRSA infections are a little harder to treat than regular staph infections

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MRSA Overview MRSA has been around for decades in hospitals (hospital-acquired MRSA, or HAMRSA) Now there are two types of MRSA: HAMRSA and community-acquired MRSA (or CAMRSA) CAMRSA started to be reported in literature about 10 years ago Although it is not required to report all MRSA infections (so we don’t have accurate statistics about how many infections there are), CAMRSA infections now are very common, and account for more than half of the skin infections seen in ERs in California

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Comparison of HAMRSA and CAMRSA CAMRSA Causes skin and soft tissue infections; serious infections rare Typically affects healthy, community-dwelling persons Resistant to penicillins (like dicloxacillin) and cephalosporins (like Keflex), but several oral antibiotics do work against it HAMRSA Serious infections common (pneumonia, blood stream infection, etc.) Typically affects sick people in hospitals and nursing homes Resistant to almost all oral antibiotics, usually need intravenous medications

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Is CAMRSA Really a Superbug? Myths and Realities Is CAMRSA resistant to all antibiotics? No, there are many antibiotics with which it can be treated Is CAMRSA killing lots of people (more people in the US dying from MRSA than AIDS) ? No, most of the deaths reported in studies occurred in older people with lots of medical problems (so they may have died of other medical problems) and most had HAMRSA infections, not CAMRSA Is CAMRSA tough to get rid of in the environment (do schools need to close down if a student is found to have a CAMRSA infection)? No, CAMRSA is killed by standard disinfectants, and school closure is not recommended Do we need to worry about CAMRSA? Don’t lose sleep over it, but learn to recognize it and respect it

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Staphylococcus aureus Colonization Colonization: bacteria living in an area, but not causing disease Areas of staph colonization: Front part of the nose (nostrils) most common place 25-35% healthy adults colonized at any one time Armpits, groin, back part of nose or throat, damaged skin, vagina or rectum can also be colonized Hands, intact skin colonized transiently MRSA can colonize the same areas, but not as commonly as regular staph (less than 1% of people colonized)

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Transmission of CAMRSA From Environmental Surfaces Unclear how much of a role environmental surfaces play Staph can survive on surfaces from hours to weeks, depending on multiple factors: Temperature and humidity Amount of bacteria Type of surface (porous versus nonporous) Availability of nutrients

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Risk Factors for CAMRSA Infection “The Five C’s” Compromised (broken) skin Contact (skin - to - skin) Contaminated items or surfaces Crowding Difficulty keeping clean (poor hygiene)

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Recognition of CAMRSA Infections “Spider bites”: pimples or pustules Boils: abscesses Cellulitis: diffuse skin infection Common signs: redness, swelling and warmth of skin Common symptoms: tenderness of skin, pain or itching

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CAMRSA Skin Infections “Spider Bites”

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CAMRSA Skin Infections Boils (Abscesses) Cellulitis

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CAMRSA Skin Infections Draining Abscesses

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Cellulitis Mild Severe

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Treatment of CAMRSA Infections Drainage: most important aspect of treatment of abscesses Antibiotics: may not be needed for all infections Wound care

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Treatment of CAMRSA – Are Antibiotics Needed for Abscesses? 69 children with CAMRSA skin and soft tissue abscess Those with large abscesses (> 5 cm) more likely to be admitted to hospital Others treated with drainage and antibiotics, but only 5 (7%) received appropriate medications before culture results back Comparison of those who received appropriate antibiotics (5) with those who did not (15): no significant differences in response! Drainage without antibiotic therapy effective management of CAMRSA skin and soft tissue abscesses <5 cm Lee et al, Pediatr Infect Dis J February 2004

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Antibiotics for CAMRSA Trimethoprim-sulfamethoxazole (Bactrim, Septra) Clindamycin (Cleocin) Doxycycline (Vibramycin) Rifampin (Rifadin): should not be used alone Linezolid (Zyvox) Vancomycin (intravenous only) Cheapest and most effective

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Wound care Keep infected area covered with bandages if open and/or draining Change bandage as often as needed to contain drainage (if wet, change it) Wear gloves if possible when changing bandages Carefully wash hands after handling bandages or any drainage from wound (even if you used gloves!)

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Work Settings and MRSA MRSA has been a long term problem in multiple healthcare settings Acute care hospitals, especially intensive care units Long term care facilities (nursing homes) Dialysis centers Many guidelines available for prevention of MRSA in these settings Mostly HAMRSA, but now both

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Work Settings and CAMRSA (2) First large outbreaks of CAMRSA noted in community starting in 2000 Affected groups included: Prisoners in jails Athletes in contact sports (football, wrestlers) Men who have sex with men (MSMs) School children Guidelines now available for competitive sports (NCAA), schools, correctional systems and non-healthcare settings (gyms, spas, etc.)

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Work Settings and CAMRSA (3) Isolate now well-established in the community, and many with infections do not belong to a traditional risk group Any worker who has significant skin-to-skin contact with others or uses shared equipment is potentially at risk Workers associated with high risk groups (prisoners, athletes, children) likely at higher risk than others

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Prevention and Control of CAMRSA Hygiene Cleaning and disinfection Surfaces Laundry Shared equipment Management of infected employees

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Personal Hygiene Frequent handwashing, dry hands with disposable towel, personal towel or air blower (do not share towels) Shower with soap and water as soon as possible after direct contact sports Bathe regularly Do not share personal care items (towels, soap, razors, etc.) Cover any cuts or scrapes with bandages to avoid infection

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Proper Handwashing

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Disinfection of Surfaces Clean surfaces before disinfection Check to make sure disinfectant is suitable for the type of surface being treated Check the label to ensure it is effective against Staph (full list of products at http://epa.gov/oppad001/chemregindex.htm) Follow manufacturer’s instructions: ensure that it is prepared properly and that it remains on the surface the recommended contact time

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Shared Equipment Use a towel or clothing as a barrier between surface of equipment and bare skin, if possible Clean and disinfect touched surfaces of equipment using a commercial Environmental Protection Agency (EPA)-registered disinfectant at least daily Repair or dispose of equipment or furniture with damaged surfaces that cannot adequately be cleaned Clean large surfaces (floors, tabletops) daily with an EPA-registered detergent disinfectant

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Steam Rooms/Saunas Encourage patrons to use towel or clothing as barrier between benches and bare skin Allow room to dry at least once daily to minimize biofilm production Clean and disinfect frequently touched surfaces at least daily Ensure that pools/spas are adequately chlorinated

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Laundry Wash items (towels, sheets, blankets, clothes, uniforms, etc.) in detergent and water > 160o F for at least 25 minutes Dry on hot temperature; do not re-use until completely dry

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Handling of Employees With CAMRSA For draining wounds, employee should not be allowed to return to work until secretions are completely contained by bandages For suspected or confirmed MRSA infection in a employee who utilizes shared equipment or whose job requires close skin-to skin contact, employee should not be allowed to use shared equipment or engage in close contact until infection is completely resolved (may need work accommodation)

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Recommendations for Worksites Encourage hand washing, and ensure that soap and warm water or alcohol-based hand sanitizers are available Not necessary to close worksite or to inform all employees if infection identified Surfaces or items that are likely to have had contact with uncovered or poorly covered infections should be cleaned and disinfected Consider educating employees on CAMRSA

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Sample Policy – Fire Department Hand Washing Before, during, and after you prepare food Before and after any patient contact even if gloves are used Before you eat and after you use the bathroom After handling animals or animal waste When your hands are dirty, and When someone in your home is sick Soap and water combined with at least 20 seconds of active scrubbing hand surfaces is sufficient. Hand soap does not need be anti-microbial. When soap and water is not available, utilize hand sanitizers or anti-microbial wipes.

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Sample Policy – Fire Department Station Hygiene Liquid soap shall be utilized in any area where items are shared; bar soap should be for individual use only. Other personal items, such as razors and towels should not be shared. All fire emergency equipment should be cleaned per department cleaning guidelines. Showers should be cleaned each morning with appropriate cleaning agents that kill staphylococcus aureus Exercise equipment should be wiped down after use and each morning. Everyone should use a towel barrier between themselves and the workbench. Utilizing hot water at temperatures of 160 degrees with appropriate laundry detergent followed by hot air dryer will kill Staph and other bacteria on clothing and linens.

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Websites for More Information State Department of Public Health: www.cdph.ca.gov http://www.cdph.ca.gov/healthinfo/discond/Pages/MRSA.aspx Centers for Disease Control and Prevention: www.cdc.gov http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html

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