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MRSA

General

In BC, CA-MRSA is not a reportable disease. Information on its distribution in the community is inferred from laboratory information, hospital epidemiology and discrete studies. Information on rates and trends of MRSA in acute care hospitals is available is available on the PICNet web site.

 

All MRSA strains are resistant to cloxacillin, oxacillin, and cephalosporins (all generations).

Hospital associated MRSA (HA-MRSA) strains are 

  • Almost uniformly resistant to macrolides, clindamycin, gentamicin, and quinolones
  • May be resistant to tetracycline, and trimethoprim-sulfamethoxazole
  • Uniformly susceptible to vancomycin and linezolid
    Community associated MRSA (CA-MRSA) strains are 
    • Usually resistant to macrolides
    • Frequently resistant to clindamycin 
    • Variably susceptibly to fluoroquinolones
    • Usually susceptible to trimethoprim-sulfamethoxazole and doxycycline.
    • Strains may also be susceptible to rifampin but this is never recommended as monotherapy as resistance can emerge rapidly
    • Uniformly susceptible to vancomycin and linezolid

    Patterns of resistance can change and optimal therapy should be guided by knowledge of the susceptibility pattern of the local area and patient’s isolate. 

     
    Guidelines for the Management of Community-Associated Methicillin-Resistant Staphylococcus aureus Infections in Primary Care:

    With the increasing rates of MRSA in the community, doctors should be encouraged to consider MRSA in the differential diagnosis of skin and soft tissue infections that look like S. aureus. In particular, infections that are pus-filled (fluctuant or palpable fluid-filled cavity, yellow or white center, central point or “head,”) should be treated through the draining or possible aspiration of pus with needle or syringe. A patient presenting with complaint of a “spider bite” should raise suspicion of a S. aureus infection.   

    Cultures and susceptibility should be taken for any serious infection, if the patient is febrile (fever) or has a purulent (pus-filled) site of infection. 

    If antibiotic therapy is necessary, culture and susceptibility is recommended.

      Community Screening:
      • Nares
      • Active screening for MRSA carriers is NOT recommended unless:
        • Recurrent S. aureus skin infections (≥2 per 6 months) despite enhanced hygiene measures
          • Individuals that are being considered for eradication
          • Closed communities or families
      Hospital Screening: 
      • Nares and groin
      • Controversy exists over screening high-risk patient groups or high-risk settings in institutions
      • The benefit of active screening and isolation are unproven without strict adherence to hand hygiene and consistent use of contact precautions

      In areas where CA-MRSA is common (most of BC), initial options for outpatient treatment include cotrimoxazole or doxycycline. 


      Note: Doxycycline should not be used in children under 8 years of age or in pregnant women. Cloxacillin or cephalexin are good initial treatments where the occurrence of CA-MRSA is rare.  Avoid using clindamycin or quinolones without prior knowledge of susceptibility as there is significant resistance. For further treatment options, please refer to the Bugs & Drugs reference book (Blondel-Hill & Fryters, 2012) and click here for webinar by Dr. Natasha Press on CA-MRSA. Skin and Soft Tissue Infections (SSTIS) Due to Staphylococcus Aureus

       

      Glossary

      Community-Associated MRSA

      An infection that occurs without exposure to a healthcare setting.  CA-MRSA is caused by distinct strains (types) of MRSA. It often begins as a painful skin boil and can spread by skin-to-skin contact or contact with contaminated objects. 

      Healthcare-Associated MRSA

      An infection that occurs from exposure to a healthcare setting. It is usually associated with invasive procedures or devices, such as surgery, intravenous tubing or artificial joints. 

      HA-MRSA may be caused by strains (types) of MRSA unique to hospitals, but also in recent years by CA-MRSA strains coming from the community. Because it often affects people in hospital who are sicker to begin with, HA-MRSA may cause more severe and potentially life-threatening infections, such as bloodstream infections, surgical site infections, or pneumonia. 

      Colonization

      When S. aureus is found on the skin without causing symptoms of infection. 

      Infection

      When S. aureus invades the body causing the immune system to react with signs and symptoms 

      Signs & symptoms

      For MRSA infection, these will vary by the type and stage of the infection. In general, patients have a high fever, a high white blood cell count and bacteria may be present in their blood and/or infected site. These patients usually require intravenous antibiotics for treatment of their infection. 

      Antiseptic

      Antiseptics are chemical agents used to reduce the number of germs on surfaces. They are normally used topically on skin and mucous membranes. 

      Cleaner

      Cleaners (e.g. soaps and detergents) are chemicals designed to remove dirt and organic material (e.g., blood, vomit, stool, germs). Cleaning physically removes rather than kills germs. It is accomplished with water, detergents and mechanical action. 

      Disinfectant

      A chemical agent that kills most germs on hard surfaces. Disinfectants are applied only to inanimate objects and should not be used on skin or mucous membranes. Disinfectants have no ability to remove dirt. Some agents are combined with a cleaner to be more effective.

      References

      1. Barton M, Hawkes M, Moore D, Conly J, Nicolle L, Allen U et al. Guidelines for the prevention and management of community-associated methicillin-resistant Staphylococcus aureus: A perspective for Canadian health care practitioners. Can J Infect Dis Med Microbiol 2006; 17(Suppl C): 4C- 24C. 

      2. Blondel-Hill E. & Fryters S. (2012). Bugs and Drugs: An Antimicrobial/Infectious Diseases Reference. Edmonton, Alberta: Alberta Health Services, 2012. 

      3. Centre for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus (MRSA) Infections. Retrieved online at: http://www.cdc.gov/mrsa/ 

      4. Health Canada. (2007). Guidance Document: Disinfectant Drugs. Retried online at http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/disinfect-desinfect/disinf_desinf-eng.php 

      5. Marra F, Patrick DM, Chong M, McKay R, Hoang L, Bowie WR. Population-based study of the increased incidence of skin and soft tissue infection and associated antimicrobial use, Antimicrobial Agents and Chemotherapy 2012; 56(12): 6243-6249. 

      6. Provincial Infection Control Network of British Columbia. (2012). Methicillin-Resistant Staphylococcus aureus (MRSA) Surveillance Report. Retrieved online at: http://www.picnet.ca/uploads/files/surveillance/MRSA%20Annual%20Surveillance%20Report%202011-2012.pdf 

      7. Popovich KJ, Hota B. Treatment and prevention of community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infections, Dermatologic Therapy 2008;21: 167-179. 

      8. Klein EY, Sun L, Smith DL, Laxminarayan R. The changing epidemiology of methicillin-resistant Staphylococcus aureus in the United States: a national observational study. Am J Epidemiol 2013;177:666-674. 

      9. Smith CH, Goldman RD. Staphylococcus aureus decolonization for recurrent skin and soft tissue infections in children. Can Fam Physician 2012;58:1350-1352. 

      10. Golding GR, Quinn B, Bergstrom K, Stockdale D, Woods S, Nsungu M, Brooke B, Levett PN, Horsman G, McDonald R, Szklarczuk B, Silcox S, Paton S, Carson M, Mulvey MR, Irvine J; Northern Antibiotic Resistance Partnership.Community-based educational intervention to limit the dissemination of community-associated methicillin-resistant Staphylococcus aureus in Northern Saskatchewan, Canada. BMC Public Health 2012;12:15. 

      11. Stenstrom R, Grafstein E, Romney M, Fahimi J, Harris D, Hunte G, Innes G, Christenson J.Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus skin and soft tissue infection in a Canadian emergency department. Can Journal Emergency Med. 2009 Sep;11(5):430-438.

      12. Dantes R, Mu Y, Belflower R, Aragon D, Dumyati G, Harrison LH, Lessa FC, Lynfield R, Nadle J, Petit S, Ray SM, Schaffner W, Townes J, Fridkin S; Emerging Infections Program–Active Bacterial Core Surveillance MRSA Surveillance Investigators. National Burden of Invasive Methicillin-Resistant Staphylococcus aureus Infections, United States, 2011. JAMA Intern Med 2013;173(21):1970-1978.

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