1. Mercy! MRSA! Gail R. Hansen, DVM, MPH State Epidemiologist Kansas Department of Health and Environment

2. Healthy Kansans living in safe and sustainable environments. Before starting, Thanks! Dr. Dan Hinthorn, KUMC Ms. Sheri Anderson, KDHE

3. Healthy Kansans living in safe and sustainable environments. Staphylococcus aureus  Gram positive cluster forming cocci  Sources Commonly carried on the skin and mucus membranes of humans Commonly carried on the skin and mucus membranes of humans Most common cause of skin infections in US Most common cause of skin infections in US A word about pets A word about pets

4. Healthy Kansans living in safe and sustainable environments. Diseases  Topical Cellulitis Cellulitis Boils Boils Impetigo Impetigo Wound infections Wound infections  Antimicrobials may not be necessary for treatment  Systemic Bacteremia Bacteremia Endocarditis Endocarditis Toxic Shock Syndrome Toxic Shock Syndrome  Require antibiotics

5. Healthy Kansans living in safe and sustainable environments. What is MRSA?  Methicillin-Resistant Staphylococcus aureus  Resistant to other beta (ß) lactamase- resistant penicillins and cephalosporins

6. Healthy Kansans living in safe and sustainable environments. Staphylococcus aureus perspective  Staphylococcus has been around as long as history Egyptian mummies Egyptian mummies 1880s--usual cause of pus from wounds 1880s--usual cause of pus from wounds Sulfa drugs reduced infections but resistance developed Sulfa drugs reduced infections but resistance developed Penicillins reduced infections but resistance developed Penicillins reduced infections but resistance developed  Staph has virulence factors & defense mechanisms that cause rapidly progressive diseases, even with normal immune systems

7. Healthy Kansans living in safe and sustainable environments. Resistance  Staph have 1 of 5 Staph Cassette Chromosomes that hold resistance factors SCC IV and V are small SCC IV and V are small  CA-MRSA, type IV. SCC I-III are large SCC I-III are large  HA-MRSA types I, II, or III The SCCmec A IV (resistance gene to methicillin) can’t hold all types of resistances due to size The SCCmec A IV (resistance gene to methicillin) can’t hold all types of resistances due to size  First described in S. epidermidis in the 1970s

8. New Resistant Bacteria Mutations XX Emergence of Antimicrobial Resistance Susceptible Bacteria Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Resistant Bacteria Resistance Gene Transfer

9. Resistant Strains Rare x x Resistant Strains Dominant Antimicrobial Exposure x x x x x x x x x x Selection for antimicrobial-resistant Strains Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

10. Healthy Kansans living in safe and sustainable environments. Staph has out-smarted us at every turn  Able to make cell walls even though methicillin should prevent that  Mortality was 70% before penicillin in 1937 1944, with penicillin--mortality 28% 1944, with penicillin--mortality 28% 1954, with  -lactamase--mortality 50% 1954, with  -lactamase--mortality 50% 1962, with methicillin--mortality 30% 1962, with methicillin--mortality 30%  S. aureus is the #1 pathogen in children

11. Evolution of Antimicrobial Resistance S. aureus Penicillin  (1950s) Penicillin-resistant S. aureus Methicillin  Methicillin-resistant S. aureus (MRSA) Vancomycin- Resistant S. aureus Vancomycin Vancomycin - intermediate resistant S. aureus (1960s) (2002) (1997)

12. Healthy Kansans living in safe and sustainable environments. PVL and severe disease  The PVL gene (Panton Valentine Leukocidin) First described in 1894 First described in 1894 Further described by P&L in 1932 Further described by P&L in 1932 It codes for a cytotoxin against WBC & RBC It codes for a cytotoxin against WBC & RBC PVL gene is not linked to SCCmec type IV PVL gene is not linked to SCCmec type IV  Found in MSSA and MSSA with PVL  Predated CA-MRSA.

13. Healthy Kansans living in safe and sustainable environments. Toxins in staph  S. aureus may have 30 extracellular products. Enzymes, cytotoxins, hemolysins etc Enzymes, cytotoxins, hemolysins etc  PVL, synergohymenotropic toxin Acts on cell membranes, forms a pore Acts on cell membranes, forms a pore  Leukocytolytic & causes severe tissue damage  Induces granule secretion, release of leukotriene B4, and IL- 8 from WBC.  May cause necrotic skin and lung damage, any age  SCCmecA typeIV  Grows faster  5X more lethal than CA-MRSA without PVL

14. Healthy Kansans living in safe and sustainable environments. Confusing names made easy  Names are by PFGE, not phage type, ~80/81 CA-MRSA are called USA-300, USA-500, USA- 1000, USA-1100. CA-MRSA are called USA-300, USA-500, USA- 1000, USA-1100.  Most resistant to erythromycin, some clinda resistance.  Most quinolone resistant and 25% resistant to tetras. HA-MRSA are called USA-100 USA-200. HA-MRSA are called USA-100 USA-200.  Most resistant to erythromycin, clindamycin, quinolones.  Most susceptible to tetra and trimethsulfa.

15. Healthy Kansans living in safe and sustainable environments. HA-MRSA  Scottish study Increased new ICU cases of MRSA related to Increased new ICU cases of MRSA related to  Nursing staff deficits  Failure to use basic infection control practices  Deficiency of environmental hygiene  160 sites cultured  Sinks, curtains, bedrails, computers 23% were positive  70% were positive from site where hand contamination occurred.  Organisms usually viewed as environmentally spread  VRE, vancomycin resistant enterococci  CDAD, Cl. difficile associated diarrhea

16. Healthy Kansans living in safe and sustainable environments. HA-MRSA Transmission  Person to person contact most important Hands of staff, transiently colonized Hands of staff, transiently colonized  Environment plays a limited role Equipment, surfaces Equipment, surfaces  Droplet-borne transmission is even less common

17. Healthy Kansans living in safe and sustainable environments. Factors that Favor HA-MRSA Transmission  High resident to staff ratios  Lack of attention to basic infection control measures  Use of common equipment without disinfection  Personal item sharing among residents  Limited facilities for handwashing  Inappropriate use of antimicrobials

18. Healthy Kansans living in safe and sustainable environments. HA-MRSA Prevention  Hand hygiene Antiseptic washing Antiseptic washing Soap and water Soap and water Waterless handrubs/alcohol Waterless handrubs/alcohol  70% better than 95%  Not for visible dirt Fake nails Fake nails  Beware donor fabrics

19. Healthy Kansans living in safe and sustainable environments. CA-MRSA  MRSA of persons who have not been hospitalized in the past year  Usually skin infections in otherwise healthy people  Virulence factors allow CA-MRSA to spread more easily or cause more skin disease  25-30% of population colonized with S. aureus 1% (?) with MRSA 1% (?) with MRSA

20. Healthy Kansans living in safe and sustainable environments. CA-MRSA Transmission  Mostly via contaminated hands Contact with infected individuals Contact with infected individuals Contact with contaminated environmental surfaces Contact with contaminated environmental surfaces  Other risk factors Skin-to-skin contact Skin-to-skin contact Crowded conditions Crowded conditions Poor hygiene Poor hygiene  Environmental contamination Not common Not common

21. Healthy Kansans living in safe and sustainable environments. The growth of CA-MRSA  MRSA reported 2 yr after methicillin was first used (1961) Predecessor to the USA300 strain Predecessor to the USA300 strain  MRSA infections started in community 1980’s Aborigines in Australia, New Zealand Aborigines in Australia, New Zealand Native American children in MN, NE, ND Native American children in MN, NE, ND MSM in LA, ATL, Boston MSM in LA, ATL, Boston Prisoners, athletes, wrestlers, football, fencers Prisoners, athletes, wrestlers, football, fencers  Majority of SSSI in ED across US now have CA MRSA  most CA-MRSA appear to be resistant to β-lactams only

22. Healthy Kansans living in safe and sustainable environments. CA-MRSA Syndromes  Necrotizing skin infections (spider bites)  Necrotizing fasciitis (“flesh eating” like strep) Pyomyositis with eos in Africa, & pyomyositis in HIV. Pyomyositis with eos in Africa, & pyomyositis in HIV.  Septic thrombophlebitis of extremities  Pelvic syndromes especially in children Septic arthritis of hips Septic arthritis of hips Pelvic osteomyelitis Pelvic osteomyelitis Pelvic abscesses Pelvic abscesses Septic thrombophlebitis Septic thrombophlebitis  Waterhouse-Friderichson syndrome  Rapidly progressive necrotizing pneumonia Develops in hours, even in previously health young people. Develops in hours, even in previously health young people.

23. Healthy Kansans living in safe and sustainable environments. CA-MRSA Prevention  Cover draining infections HCW off work until open wounds healed. HCW off work until open wounds healed.  Wash hands during day during day after toileting after toileting before eating before eating  Don’t share personal items

24. Healthy Kansans living in safe and sustainable environments. CA-MRSA Prevention  Wash linens in hot water  Dry clothes in hot dryer, not air drying  Shower after group sports, gym use, sauna, steam room or tanning With draining wounds, no athletic competition With draining wounds, no athletic competition Clean communal surfaces at gym Clean communal surfaces at gym  Immunization so far not effective

25. Healthy Kansans living in safe and sustainable environments. Spider bite or MRSA?  Start with an itch, then painful  Get worse and not better with local treatment  Both have central necrosis Look blackish or dark red or purple in center Look blackish or dark red or purple in center  Surrounding induration and erythema  Slow to resolve Neither Keflex nor Dapsone work Neither Keflex nor Dapsone work  Did you see the spider?

26. Photo courtesy of Dr. D. Hinthorn, KUMC

27. Healthy Kansans living in safe and sustainable environments. Treatment for MRSA  Incise and drain abscesses  Culture, culture, culture! Results of susceptibility determine antimicrobials Results of susceptibility determine antimicrobials  Antimicrobials Vancomycin Vancomycin  VRSA and VISA Trimeth-sulfa Trimeth-sulfa Doxy or minocycline Doxy or minocycline Clindamycin Clindamycin Quinolones? No Quinolones? No

28. Healthy Kansans living in safe and sustainable environments. Surveillance  Communication between facilities about MRSA + patients  Review culture and susceptibility data  Maintain confidential line listing of MRSA + patients  Flag MRSA+patients to assist with precautions  Active surveillance cultures for MRSA? Not be a routine measure Not be a routine measure Maybe during an outbreak Maybe during an outbreak Routine culture and treatment in hospitals not effective in reducing MRSA Routine culture and treatment in hospitals not effective in reducing MRSA

29. Healthy Kansans living in safe and sustainable environments. Reporting Requirements  Single cases of MRSA are not reportable in KS or MO  Outbreaks are reportable in KS and MO  Other states different VRSA or VISA reportable from any site VRSA or VISA reportable from any site MRSA reportable if isolated from sterile site MRSA reportable if isolated from sterile site S. aureus reportable if it results in a serious infection resulting in death or admission to ICU S. aureus reportable if it results in a serious infection resulting in death or admission to ICU MRSA labs reportable only MRSA labs reportable only All MRSA infection reportable All MRSA infection reportable

30. Healthy Kansans living in safe and sustainable environments. MRSA Outbreaks  2 or more patients with MRSA infection that are epidemiologically linked Roommates in LTC, cared for by the same staff Roommates in LTC, cared for by the same staff 2 members of the football team 2 members of the football team  Infections have temporal relationship  Call KDHE-OSE at 877-427-7317 Report outbreak or request assistance Report outbreak or request assistance

31. Questions ? ? ? 877-427-7317