CA-MRSA

An update
Dr.T.V.Rao MD
What Are
Staphylococcus aureus?
Staphylococcus aureus
(S. aureus) is a bacteria
normally found on the
skin or in the nose of 20 to
30 percent of healthy
individuals. When S.
aureus is present without
causing symptoms, it is
called colonization.
If symptoms are
present, it is called an
infection.
What are MRSA?
Methicillin-resistant
Staphylococcus aureus
(MRSA) is a strain of S.
aureus that is resistant to
methicillin, an antibiotic in the
same class as penicillin, and
is traditionally seen in people
who have been recently
hospitalized or who have been
treated at a health care facility
(such as treatment at a
dialysis centre).

What are MRSA
Methicillin-resistant Staphylococcus aureus
(MRSA) is a bacterium responsible for several
difficult-to-treat infections in humans. It is also
called oxacillin-resistant Staphylococcus aureus
(ORSA). MRSA is any strain of Staphylococcus
aureus that has developed, through the process of
natural selection, resistance to beta-lactam
antibiotics, which include the penicillins (methicillin,
dicloxacillin, nafcillin, oxacillin, etc.) and the
cephalosporins.
What are MSSA
Strains unable to resist these antibiotics are
classified as methicillin-sensitive Staphylococcus
aureus, or MSSA. The evolution of such
resistance does not cause the organism to be
more intrinsically virulent than strains of
Staphylococcus aureus that have no antibiotic
resistance, but resistance does make MRSA
infection more difficult to treat with standard
types of antibiotics and thus more dangerous.

What is CA-MRSA?
Community-associated
MRSA infections (CA-
MRSA) are MRSA
infections in healthy
people who have not
been hospitalized or had
a medical procedure
(such as dialysis or
surgery) within the past
year.
Staphylococcus aureus are
HA- MRSA and CA- MRSA
S. aureus is most common cause
of healthcare-associated
infections
MRSA is the major antibiotic-
resistant organism in hospitals;
however CA-MRSA increasing
Newer type of MRSA
Emerging
Another type of MRSA infection has occurred in
the wider community among healthy people.
This form, community-associated MRSA
(CA-MRSA), often begins as a painful skin
boil. It's spread by skin-to-skin contact. At-risk
populations include groups such as high
school wrestlers, child care workers and people
who live in crowded conditions.
What are the symptoms associated
with CA-MRSA infection?
CA-MRSA infections
typically begin as skin
infections. They first
appear as reddened
areas on the skin, or
can resemble pimples
that develop into skin
abscesses or boils
causing fever, pus,
swelling, or pain.
Complications with MRSA
MRSA infections can resist the effects of many common
antibiotics, so they are more difficult to treat. This can
allow the infections to spread and sometimes become
life-threatening.
MRSA infections may affect your:
Bloodstream
Lungs
Heart
Bones
Joints

Molecular Epidemiology of CA-MRSA
Otter, Lancet ID, 2010
S. aureus acquires resistance to methicillin
and its ability to express different virulence
factors

MRSA Colonizes
S. aureus most commonly
colonizes the anterior nares
(the nostrils). The rest of the
respiratory tract, open
wounds, intravenous
catheters, and the urinary
tract are also potential sites
for infection. Healthy
individuals may carry MRSA
asymptomatically for periods
ranging from a few weeks to
many years.
Immune compromised at
increased Risk with MRSA
Patients with
compromised
immune systems
are at a
significantly
greater risk of
symptomatic
secondary
infection.

CA-MRSA Epidemiology
neonates, children
homeless, incarcerated, IVDU
MSM, HIV-infected
military personnel
athletes (contact sports)
native aboriginals
household contacts
veterinarians, livestock handlers
David, Clin Microbiol Rev 2010
Risk factors for CA-MRSA

Participating in contact sports. MRSA can spread
easily through cuts and abrasions and skin-to-skin
contact.
Living in crowded or unsanitary conditions. Outbreaks
of MRSA have occurred in military training camps,
child care centres and jails.
Men having sex with men. Homosexual men have a
higher risk of developing MRSA infections.

MRSA in Domestic Pets
Reported in cats,
dogs, guinea pigs,
parrots
a variety of clones,
often HA-MRSA
(Weese, Vet Microbiol 2006;
David, Clin Microbiol Rev 2010)
CA-MRSA as a Cause of
Healthcare-Associated Infections
USA400 post-partum infections, NY mastitis, cellulitis,
abscesses (Saiman, CID 2003)
USA300 prosthetic joint infections, SSIs (Kourbatova, Am J
Infect Control 2005; Patel, J Clin Microbiol 2007)
USA300 accounted for 28% healthcare-associated
bacteremias, 20% nosocomomial MRSA BSIs, Atlanta,
GA (Seybold, CID 2006)
USA300 transmission in a Canadian Burn unit (McGuire,
SHEA 2007)
CA-MRSA:
Enhanced Virulence?
Associated with severe and recurrent SSTI,
often in individuals without predisposing risk
factors
Associated with necrotizing pneumonia
Appears to be easily transmitted in hospitals,
households, and the community
MRSA USA300 Virulence Factors
David, Clin Microbiol Rev 2010
CA-MRSA
Virulence
Panton-Valentine Leukocidin (PVL)
-hemolysin (increased expression in CA-MRSA; -
hemolysin antibody protective in mouse model)
(Wardenburg, Nature Med 2007)
Argenine catabolic mobile element (ACME; unique to
CA-MRSA, S. epidermidis; may help strain evade host
response and facilitate colonization) (Goering, J Clin Microbiol
2007)
How is it transmitted?
CA-MRSA is spread in
the same way as an
MRSA infection, mainly
through person-to-
person contact or
contact with a
contaminated item
such as a towel,
clothing or athletic
equipment.
How is it transmitted?
Bacteria that exist
normally on the skin
cause CA-MRSA and
so it is possible to
infect a pre-existing
cut not protected by
a dressing or other
bandage.


PVL Gene and Virulence
Using isogenic PVL
knockout mutants in
murine models (subcut
abscess, pneumonia)
has given conflicting
results (Voyich,
J Infect Dis 2006; Labandeira-
Rey, Science 2007)
PVL does appear to
contribute to virulence in
a rabbit bacteremia model
(An Diep, PLoS ONE 2008)
MRSA Impact
Attributable mortality and
morbidity
(Whitby, Med J Austr 2001;
Cosgrove, Clin Infect Dis
2003)
Prolonged hospital length
of stay
(Engemann, Clin Infect Dis 2003;
Cosgrove, Infect Control Hosp Epidemiol
2005)
Antibiotic resistance
MRSA is the result of decades of often unnecessary
antibiotic use. For years, antibiotics have been
prescribed for colds, flu and other viral infections that
don't respond to these drugs. Even when antibiotics
are used appropriately, they contribute to the rise of
drug-resistant bacteria because they don't
destroy every bacteria they target. Bacteria live
on an evolutionary fast track, so germs that survive
treatment with one antibiotic soon learn to resist
others.
What about hVISA?
hVISA (heteroresistant): MIC susceptible
(< 4 g/ml), but with a resistant sub-
population; detected by PAP-AUC
preliminary step towards development of
VISA (Hiramatsu, Lancet ID 2001)
may be associated with treatment failure
(Sakoulas, Antimicrob Agents Chemother 2005)
Vancomycin and Treatment
Failure
higher vancomycin MICs associated with
worse outcome
thus: recommendations to use higher
vancomycin doses
(target trough: 15-20 g/ml)
(Liu, Clin Infect Dis 2011)
but, higher troughs not associated with
better outcome; associated with increased
nephrotoxicity
(Hidayat, Arch Intern Med 2006)
MRSA Infection Control
Strategies
Contact
precautions
Screening
Decolonization
MRSA Decolonization
Decolonization to prevent staphylococcal SSI
(Bode, N Engl J Med 2010)
Observational studies with mupirocin or other
agents as part of infection control measures
(Hill, J Antimicrob Chemother 1998; Strausbaugh, ICHE 1992; Sandri, ICHE
2006; Ridenour, ICHE 2007; Bowler, ICHE 2010)
Interrupted time-series analysis in 2 UK ICUs:
chlorhexidine gluconate baths reduced MRSA
transmission, but emergence of strains with
reduced susceptibility to CHG (Batra, Clin Infect Dis 2010)
How can the spread of CA-
MRSA be controlled?
Careful hand washing is the single most
effective way to control the spread of CA-
MRSA. Skin infections caused by MRSA
should be covered until healed, especially to
avoid spreading the infection to others.
Family members and others with close
contact should wash their hands frequently
with soap and water. Personal items that may
be contaminated (towels, razors, clothing,
etc.) should not be shared
Preventing CA-MRSA
Wash your hands.
Careful hand-washing
remains your best
defence against germs.
Scrub hands briskly for
at least 15 seconds,
then dry them with a
disposable towel and
use another towel to
turn off the faucet.
Keep wounds covered.
Keep cuts and
abrasions clean and
covered with sterile,
dry bandages until they
heal. The pus from
infected sores may
contain MRSA, and
keeping wounds
covered will help keep
the bacteria from
spreading.
Keep personal items personal.
Avoid sharing
personal items such
as towels, sheets,
razors, clothing and
athletic equipment.
MRSA spreads on
contaminated
objects as well as
through direct
contact.
Shower after athletic games
or practices
Shower
immediately after
each game or
practice. Use
soap and water.
Don't share
towels.
Sanitize linens
If you have a cut or
sore, wash towels and
bed linens in a washing
machine set to the
hottest water setting
(with added bleach, if
possible) and dry them
in a hot dryer. Wash
gym and athletic clothes
after each wearing.
How can the spread of CA-MRSA
be controlled?
Both the Centres for Disease Control and
Prevention (CDC) and the National Collegiate
Athletic Association (NCAA) have issued
recommendations for preventing the spread of
MRSA among athletes. These include practicing
good personal hygiene, including showering
after practices and competitions and not sharing
personal items such as towels
How can the spread of
CA-MRSA be Controlled?
Athletes who participate in
sports where equipment is
often collectively used are
encouraged to reduce sharing
as much as possible and to
regularly wipe-down
equipment/mats with
commercial disinfectants or a
1:100 solution of diluted
bleach (one tablespoon
bleach in one quart water).

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