COMMUNITY-ASSOCIATED MRSA

ASSOC PROF DR. ARIZA ADNAN

FACULTY OF MEDICINE
UNIVERSITI TEKNOLOGI MARA
 Contents

• Introduction
• Key Clinical Features
• Laboratory Diagnosis
• Treatment
• Control and Prevention
INTRODUCTION
 Infection Classification
Infections historically identified based on
location and time of symptom onset as:

• community acquired: hospitalization ≤ 48

hours

or

• hospital acquired: hospitalization > 48 hours

 Community-Associated MRSA:
CDC Population-Based Surveillance Definition 1

MRSA positive culture in outpatient setting or

within the first 48 hours of hospitalization AND
patient lacks risk factors for healthcare-
associated MRSA:

• Hospitalization
• Surgery
• Long-term care
• Dialysis
• Indwelling devices
• History of MRSA
 CA-MRSA 2

• CA-MRSA is distinct from HA-MRSA

• Clones of CA-MRSA are spreading with alarming

rapidity

• CA-MRSA: “old foe with new fangs”

• A pathogen combining virulence, resistance and

ability to disseminate at large
Population at risk of CA-MRSA 3
• Children less than 2 years old

• Atheletes (contact-sports)

• Inmates in correctional facilities

• Military recruits

• Daycare attendees

• Injecting drug users

CLINICAL MANIFESTATIONS
 Factors that Facilitate Transmission: “5 Cs”
4
OverCrowding

Frequent skin Contact

Contaminated surfaces
Compromised skin and shared items Lack of Cleanlinesss
 CA-MRSA Infections are Mainly Skin Infections 5

Disease Syndrome

• Skin/soft tissue 1,266 (77%)

• Wound (Traumatic) 157 (10%)
• Urinary Tract Infection 64 (4%)
• Sinusitis 61 (4%)
• Bacteremia 43 (3%)
• Pneumonia 31 (2%)

Fridkin et al NEJM 2005;352:143

 Comparison of Clinical, Epidemiological and Microbiological Characteristics of
Community-associated (CA)-MRSA and Healthcare-associated (HA)-MRSA
Characteristic HA-MRSA CA-MRSA
Population affected Hospital/healthcare/nursing Usually young healthy individuals
home patients/residents. in the community.
Elderly. Those who have NO risk factors for
Preterm neonate. acquisition of HA-MRSA.
Immunocompromised. Individuals in prisons, military
personnel, athletic population
(especially those involved in
combat and ball sports),
male homosexuals

Site of infection Bacteraemia and wound Mainly skin (abscesses and cellulitis,

infections. furunculosis, severe skin and soft

Symptomatic infections of
respiratory and urinary tracts.
Risk factors Indwelling devices, catheters,
lines, haemodialysis, prolonged
hospitalisation, long-term
antibiotic use.
Transmission (i) Person-to-person spread:
healthcare staff (e.g. nurses,
doctors, surgeons, physiotherapists),
Visitors,patients
(ii) Environment-to-patient
spread, e.g. hospital equipment
Microbiological characteristics
tissue infections.
In severe cases, septic shock and
bacteraemia.
Necrotising pneumonia.
Close physical contact, abrasion
injuries, activities associated with
poor communal hygiene (e.g.
sharing towels).
(i) Person-to-person spread.
Shared facilities (e.g. sports
equipment, towels, pools, etc.).
(ii) Environment-to-person spread,
e.g. shared sports equipment

(S) methicillin No No
(S) to other No Yes (in majority of cases)
antibiotic agents
(fluoroquinolones,
aminoglycosides, erythromycin,

clindamycin)

Presence of PVL gene Low (<5%) High (>95%)

SCCmecA type Predominantly subclasses I, II or III Mainly IV

Community-associated MRSA: Superbug at our doorstep. CMAJ 2007; 176(1): 54-56

LABORATORY DIAGNOSIS
How should clinical laboratories screen for MRSA?
7

The Clinical and Laboratory Standards Institute

(CLSI), recommends:

• cefoxitin disk screen test

• latex agglutination test for PBP2a OR

• plate containing 6 μg/ml of oxacillin in Mueller

Hinton agar supplemented with NaCl as
alternative methods
What are the susceptibility patterns CA-MRSA?

• HA-MRSA isolates often are multiply

resistant to ALL ß-lactam agents as
well as erythromycin, clindamycin,
and tetracycline,

However,

• CA-MRSA isolates are generally

resistant only to ß-lactam agents and
erythromycin. But, multi-resistant
phenotyopes are not uncommonly
encountered and thus presumptive
diagnosis based on antibiogram is
sometimes NOT reliable
 Laboratory confirmation of CA-MRSA

• Upon isolation of MRSA isolates with clinical and

epidemiological suspicion of CA-MRSA, further
laboratory characterization is required:

1.SCCmec typing CA-MRSA strains harbour SCC mec

2.PVL gene type IV and PVL gene POSITIVE

• The technique employed is PCR

 Epidemiological Typing

i. Pulsed-field gel electrophoresis (PFGE)

ii. Multilocus sequence typing (MLST) and
iii. S.aureus protein A (spa) typing

• These methods are employed when it is

necessary to delineate epidemiological
relationships among CA-MRSA strains isolated
from different sources, such as in outbreak
investigations
 TREATMENT

Strategies for Clinical Management of MRSA in the Community

CDC 2006
 Management of Skin Infections in the Era of
CA-MRSA (1) 10

• I&D should be routine for purulent skin lesions

• Obtain material for culture

• Empiric antimicrobial therapy may be needed

• Alternative agents have +’s and –’s: More data

needed to identify optimal strategies
 Management of Skin Infections in the Era of
CA-MRSA (2)
10

• Use local data for treatment

• Patient education is critical

• Maintain adequate follow-up

• No data to suggest molecular typing or toxin-

testing should guide management
 Treating MRSA infections

Agents with MRSA activity include:

Vancomycin Linezolid Daptomycin

Tigecycline TMP-SMX Clindamycin

 Treating MRSA infections
11
Limitations of some agents:
• Clindamycin – Potential for inducible resistance, Relatively
higher risk of C. difficile associated disease?
• Rifampin – Not as a single agent
• Linezolid – Expensive, potential for resistance with
inappropriate use

NOT optimal for MRSA (High prevalence of resistance or potential

for rapid development of resistance):
• Macrolides X
• Fluoroquinolone X
 Treating MRSA infections
12

• Vancomycin remains a 1st-line therapy for severe

infections possibly caused by MRSA

• Other IV agents may be appropriate. Consult an

infectious disease specialist.

• Final therapy decisions should be based on

results of culture and susceptibility testing

• Severe community-acquired pneumonia:

Vancomycin or linezolid if MRSA is a
consideration
 Prevention in the hospital

Core Strategies:

• Assessing hand hygiene practices

• Implementing contact precautions
• Recognizing previously infected patient
• Rapidly reporting laboratory results
• Providing CA-MRSA education to healthcare workers
 Assessing hand hygiene practices

o Hand hygiene should be a cornerstone of prevention

efforts
• Prevents transmission of pathogens via hands of
healthcare personnel

o As part of a hand hygiene intervention, consider:

• Ensuring easy access to soap and water/
alcohol-based hand gels
• Education for healthcare personnel and patients
• Observation of practices - particularly around high-
risk procedures (before and after contact with
colonized or infected patients)
• Feedback – “Just in time” feedback if failure to
perform hand hygiene observed
 Implementing contact precautions

Involves use of gown and gloves for patient care

• Don equipment prior to room entry
• Remove prior to room exit

Single room (preferred) or cohorting for

MRSA colonized/infected patients

Use of dedicated non-essential items may help decrease transmission

due to contact with these fomites
• Blood pressure cuffs
• Stethoscopes
• IV poles and pumps
 Recognizing previously infected patient
-Screening

• Patients can be colonized with MRSA for months

• There is no single ‘best’ strategy for

discontinuation of isolation precautions for MRSA
patients

• Being able to recognize previously colonized or

infected patients who have not met criteria for
discontinuing isolation allows them to be
subjected to interventions in a timely fashion
 Rapidly reporting laboratory results

• Facilities should have a mechanism for

rapidly communicating positive MRSA results
from laboratory to clinical area

• Allows for rapid institution of interventions on

newly identified MRSA patients
 Providing CA-MRSA Education to Healthcare Workers

• To improve adherence to hand hygiene

• To improve adherence to
interventions
(e.g., Contact Precautions)

• Encourage behavioral change through a better

understanding of the problem
 Prevention 13
Goal: to prevent spread of CA-MRSA from infected or
colonized individual to others in the family or
community
Prevention
Although the CA-MRSA superbug is advancing…..
It is important to take every preventive effort not to
welcome it inside our borders!
DON’T give bacteria a free ride…..