Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

MRSA Infections:A Deadly But Preventable Disease-Kelly Donnelly

Methicillin-resistant Staphylococcus aureus (MRSA) infections have emerged in patients who do not have established risk factors and currently our systems are not doing enough to prevent the increasing risks of our citizens. In the United States, Staphyloccus aureus is the most common cause of skin and soft-tissue infections, as well as of invasive infections acquired in hospitals (1). According to CDC data, the proportion of infections that are antimicrobial resistant has been on the rise (2). In 1974, MRSA infections accounted for two percent of the total number of staph infections; in 1995 it was 22%; in 2004 it was 63%. Over the past 20 years, these infections have been limited to patients in hospitals or long-term care facilities but a more infectious strain is causing grave illnesses and deaths in our healthy communities.

MRSA is a strain of a super bug that has been found in non-hospitalized patients and is becoming a common and serious problem. These infections usually involving the skin or soft tissues are normally found on the skin or nose in about one third of the population. If you have staph on your skin or in your nose but aren’t sick, you are said to be colonized but not infected with MRSA. Healthy people can be colonized with MRSA and have no ill effects, however, they can pass the germ to others (3). The good news is it is still treatable with drugs. But as this super bug becomes more infectious and resistant to more antibiotics it poses a considerable public health risk. Failures in our communities at the Local, City and State levels are equally responsible for this deadly super bug resistance and its continued spread. Locally, our doctors are over prescribing antibiotics, the cities hospitals have inadequate infection control procedures and our state continues to have overcrowded living conditions.

MRSA is considered to be a superbug infection, that has evolved from a variety of sources one that includes decades of excessive and unnecessary antibiotic use. Since their inception in the 1940’s antibiotics have been over used. Although prescription antibiotics are the main culprit they are not the only one. In the US, antibiotics are in everything from our food to our water system. Exposure to antibiotics is unique to the US because other countries have stricter regulations on antibiotic use. Unlike the US, other countries forbid antibiotic use in animals so that these types of resistant bacteria are not easily formed. The increased frequency of antibiotics should be of great concern to medical providers and the public. Since the development of these novel antibiotics their use has been for everything including the common cold or flu but as we now know most of these aliments are unaffected by antibiotics and eventually resolve on their own.

To keep antibiotic resistance under control, reduced levels of antibiotic prescribing must be more consistent. Antibiotics should be used only when medically necessary and not for everyday medical problems. Doctors also need to encourage patients to finish their whole course of antibiotics regardless of whether or not they feel better. When patients finish their medication as instructed by their doctor they decrease the chance of infections returning. Continuity of patient care should also continue even after the patient leaves the doctors office with continued follow up with the patient.

There are individual and social factors that can help reduce the number of these infections. One solution would be for doctors to refrain from prescribing antibiotics for common viruses. Another recommendation would be for doctors to call patients a few days after treatment to assess the resolution of illness while giving patients an opportunity to clarify any new or unresolved issues about their treatment or medication.

Infection control measures need to be improved in hospitals too. Why is it that these infections are now being reported in healthy non-hospitalized persons who have not been in direct contact with a healthcare provider or colonized patients? Once thought of as a “hospital acquired infection” it is now spreading in epidemic proportions to otherwise healthy individuals. In addition, MRSA infections are common in patients who have indwelling vascular catheters for dialysis or other medical treatments. However during the past decade, multiple reports of these infections have been reported in patients who lack the above risk factors (4). This raises some serious concern about the transmission of MRSA outside of the healthcare system.

Infection control protocols and procedures within the doctor’s office, clinics and hospitals are vital in preventing the compromised and non compromised patients from acquiring this disease. Doctors’ offices and clinics are understaffed and overbooked with patients causing staff to focus attention on seeing more patients which allows less time between patients to disinfect or properly wash hands in between patients. Having worked in these types of settings for many years, I personally have observed staff only washing their hands less than half the time they should. I have even observed staff not changing gloves between patients as they should. Hand-washing is the most simplistic and preventable way of spreading germs, yet it is improperly done by the most people as well as medical staff.

Person to person contact is the leading spread of this disease. To help prevent spread of this super bug hospitals should require staff and visitors to wear gloves and gowns while visiting patients if the cause of their sickness is unknown. Clinicians also need to take part in the emergence of this super bug and stop its spread throughout the community. Clinicians need to be educated in using the appropriate antibiotic therapy and know when to initiate it as soon as infection with this pathogen is suspected (5).

Over crowded living conditions is a major breeding ground for this communicable disease. Homeless shelters and people forced to live in community homes continue to struggle to have adequate housing with more people and less housing. Due to the lack of resources and low economic status of these families they are forced to share personal belongings, blankets, and clothes. By sharing these items it puts these people at higher risk of acquiring this disease. Communities with people living under these stressful housing situations are also less likely to have access to good medical resources. These same families don’t have or can’t afford medical care for treatment of sickness and not to mention preventative care. So what may appear to be a spider bite to a person in this crowded community may indeed be a sign of a MRSA infection but it may go unnoticed and untreated.

Institutions such as prisons, schools, and colleges are other community locations that are at high risk for getting MRSA infections. Prisons are exceptionally susceptible to communicable disease just by the mere fact that inmates are living in extremely close quarters of one other. The risk of promiscuous, unprotected sex, same sex is high in prison. Prisoners may have open sores and cuts but receive less medical attention or intervention. This disease presents as a mild skin infection but can develop into something more serious such as sepsis or organ failure without proper diagnosis and treatment. In college, students are at especially high risk. Students in school may be apt to share things like towels and razors both of which can potentially carry this germ.

If college students are involved in sports especially contact sports they are at especially high risk. Since MRSA is so contagious anything such as sharing towels or sports equipment could expose you to this germ. Football, basketball and wrestling have the highest incidence of MRSA because of the physical contact, and the most prominent areas of infection include the lower leg, forearm and knee (6).

Those with HIV or auto immune diseases are at especially high risk due to their weakened immune systems. These days it’s imperative that you be your own health advocate and help assist in advocating for those that are sick and young in our community. Schools too need to do more to protect our children and to educate their parents on MRSA infection and its spread. One solution may be for information to be sent home on a more regular basis about the spread of disease and not just when a crisis strikes-- because by then it’s too late. All information should be disseminated in a variety of ways and in those languages appropriate to the community.
Prevention methods need to be taught and enforced and accountability needs to be given to all facilities including: schools, hospitals, rehabilitation centers and elderly facilities. But currently there are no mandatory reporting procedures in schools, and according to the CDC; the decision to make a particular disease reportable to public health authorities is made on the state level based on the needs of that state.

Information is power--so its time to contact your local and state political offices with phone calls and letters demanding that this contagious communicable disease be reported because this disease is not prejudice and it has no racial or socioeconomic boundaries, it affects all. The public needs to be informed and educated about MRSA and its potential spread. Massive public education campaigns need to be able to educate and inform those with and without computers and be multi-lingual and in all public places. Hospital protocols and procedures should be strictly followed in all hospitals and by all staff and accountability taken when they are not. Continued education and in-services on proper hand washing techniques are necessary for all staff on a regular basis or as staff change and turn over.

Schools need to educate staff and students on prevention and susceptibility of this disease. Because this disease is more commonly spread by hands through person to person contact with an infected person it can also be transmitted by towels, clothes and other objects. Schools should make it mandatory and forbid sharing of personal items. School personnel and coaches need to constantly remind athletes and parents to make sure all equipment and clothes are washed thoroughly after each use. But good hygiene is one of the most fundamental ways to avoid its spread. Showers should also be mandatory before and after physical sports or contact games and locker rooms should disinfected daily. All staff need to take part in disease prevention.
Well-designed, community based studies with adequate risk factor analysis are required to further elucidate the epidemiology of CA-MRSA and to improve strategies to control MRSA in both the community and hospital settings (6).

The spread of MRSA is preventable. Despite marked efforts, prevention, spread and patient safety have not improved. There is simply not enough being done to prevent the spread of MRSA and not nearly enough being done to educate the public on its prevention. Targeted educational interventions are needed to increase awareness and improve prevention and management of these infections. Our local hospitals, city community services and state representatives have failed us here. MRSA is only one really important reason why public health officials need to persuade the public to share the responsibility for infection control and adopt better standards of day-to-day hygiene. To achieve this shared responsibility, however, we need to abandon our fragmented approach to hygiene promotion and adopt a concerted approach that looks at hygiene from the point of view of the family and the range of problems that they face in protecting themselves from infection (8). If we had more forward-thinking by our authorities this too could be another avenue where we could curb the continued resistance of this super bug.

REFERENCES
1. National Center for Infectious Disease. Methicillin-resistant Staphyloccus
aureus (MRSA), 2003. http://www.cdc.gov/ncidod/aip/research/mrsa.html

2. Department of Health and Human Services. Centers for Disease Control and
Prevention. MRSA in Healthcare Settings, 2007. http://www.cdc.gov/ncidod/dhqp/ar_MRSA_spotlight_2006.html

3. Mayo Clinic. Infectious Disease. MRSA Infection.
http://www.mayoclinic.com/health/mrsa/DS00735

4. Emerging Infectious Disease 13.8 (August 2007): p 1195 (6)

5.Curr Opin Infect Dis. 2006 Apr; 10 (2): 161-8 Pub Med. http://www.ncbi.nlm.nih.gov/sites/entrez?

6. IDEA Fitness Journal 4.8 (Sept 2007): p 17 (1).

7. Clin Microbiol Infect. 2006 Mar;12 Suppl 1:9-15. PubMed.
http://www.ncbi.nlm.nih.gov/sites/entrez?

8. Gould IM. CAMRSA: can we control it? Lancet 2006; 368: 824-26

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