Authors

  1. McGuckin, Maryanne Dr ScEd, MT (ASCP)

Article Content

Health-care-acquired infections (HAI), previously referred to as nosocomial infection, caused by antibiotic-resistant pathogens is an ongoing topic of debate in the health care industry. Patients with wounds may be at a higher risk for contracting these pathogens.

 

The Centers for Disease Control and Prevention (CDC) has estimated that approximately 13,300 Americans died in 1992 of health-care-associated infections caused by antibiotic-resistant pathogens. Using that figure, it can be estimated that 130,000 to 150,000 patients have died of these infections in US hospitals during the past decade. 1

 

Methicillin-resistant Staphylococcus aureus (MRSA) was first recognized in Europe and the United States in the late 1960s, 2,3 and is now evidenced worldwide. In fact, MRSA accounts for a growing proportion of S aureus isolated from hospitalized patients in many countries. According to 2003 National Nosocomial Infections Surveillance reports, the proportion of intensive care unit patients with S aureus nosocomial infections resistant to oxacillin has increased from 30% in 1989 to 60% in 2003. 4

 

Once considered only a nosocomial pathogen, MRSA appeared in nonhospitalized patients in 1980, primarily among intravenous drug users. 5,6

 

Debate over the prevalence of MRSA in the community setting continues today. Some studies illustrate the spread of MRSA within community settings, but others report that MRSA transmission occurs only in health care institutions. 7-14 In 2003, Jernegan et al 15 conducted a prevalence study of MRSA colonization among patients presenting to a university hospital by performing surveillance cultures at the time of hospital admission. Of the 974 patients cultured, 21% had S aureus isolated, and 26 (2.7%) had MRSA, representing 12.7% of all patients colonized with S aureus.15 The independent predictors of MRSA colonization in the study's population were admission to a nursing home in the previous year or a hospitalization of 5 days or longer during the preceding year.

 

These findings are contrary to those of other investigators reporting on the emerging of MRSA as a community pathogen. These studies, however, are retrospectively dependent on microbiology reports and use criteria of culture positive less than 48 hours after admission. 7-10 Because MRSA can persist for months or years, it is difficult to distinguish between true community-acquired and health care-acquired colonization. 16

 

Two other prospective studies, supporting the finding that MRSA isolated from patients on admission to a hospital correlated with a previous health care system admission, suggest that community-acquired MRSA is uncommon. 17,18 It may be possible that community-acquired MRSA is dependent on a geographic factor or specific high-risk population, such as, children in day care, inmates, sport teams, Native Americans, and other minorities. 19,20,21

 

In addition, acute rehabilitation units are considered high-risk populations for MRSA colonization/infection because the majority of those patients are transferred from an acute care hospital or nursing home. 22

 

Manian et al 23 looked at routine screening for MRSA on admission to acute rehabilitation units and reported a 12% isolation rate for MRSA on newly admitted patients and 7% for in-house transfers.

 

Of note to wound care practitioners, the first 2 cases of VRSA in the United States involved patients with chronic lower extremity ulcers.

 

History of MRSA infection/colonization and transfer from outside sources were independently associated with positive MRSA screening cultures. However, this represented only 37% of the patients admitted with MRSA colonization, suggesting the value of screening cultures for all admissions.

 

A new resistant organism emerges

These studies indicate that identifying MRSA-colonized patients is necessary if we are to understand the epidemiology of this organism and apply it to the newest resistant organism, vancomycin-resistant Staphylococcus aureus (VRSA). In addition, patients with colonized MRSA during their hospitalization need postdischarge follow-up. A recent report showed that approximately 50% of MRSA infections in patients who were initially identified to be colonized in a health care setting occurred after discharge. 24 These infections were often severe and involved soft tissue, pneumonia, and osteomyelitis.

 

VRSA is also emerging in the health care setting. The CDC reported 8 confirmed cases in the United States, and reported cases in France, Hong Kong, Scotland, Japan, and Korea. Current evidence indicates 2 risk factors for infection with VRSA: the use of vancomycin in the prior month and previous MRSA-positive culture. 25

 

The first 2 cases of VRSA (1 in Michigan, 1 in Pennsylvania) occurred in the summer of 2002 and in the outpatient setting. Both patients had lower extremity ulcers. Table 1 illustrates the characteristics of each case and exposure facts.

  
Table 1 - Click to enlarge in new windowTable 1. 2 CASES OF VANCOMYCIN-RESISTANT

Based on available data, 3 facts that are known about these resistant bacteria:

 

* prevalence in the health care setting is increasing

 

* transmission occurs outside of the health care setting

 

* VRSA is emerging.

 

 

How do these trends affect the wound care patient and health care provider? And, what can be done to control the spread of MRSA/VRSA?

 

If not hospitalized, patients with acute or chronic wounds are usually treated in long-term-care facilities, wound clinics, rehabilitation units, or the home. These settings have been shown to significantly affect colonization or infection with MRSA/VRSA. Although wound culturing has not been shown to provide clinically relevant information, surveillance cultures for MRSA/VRSA may be indicated in this patient population. In fact, this may affect the prevalence of MRSA. Many hospitals have been reluctant to conduct surveillance cultures, but several studies have shown that screening high-risk patients and having established infection control policies can provide control of MRSA. 24,25

 

Patients with wounds, especially chronic lower extremity wounds, can be considered high risk because of an underlying condition, frequent access to health care, or residency in long-term-care settings. All these factors are considered to predispose the patient to MRSA/VRSA.

 

Making an Impact on MRSA/VRSA

Wound care providers can make the same impact on MRSA as did the Rhode Island infection control practitioners in 2002 when they decided that the increasing MRSA prevalence needed a collaborative, statewide solution. The guidelines they developed and distributed have made them leaders in MRSA control measures. Wound care professionals could take the same stand.

 

The gap between evidence and practice is a consistent finding in research of health service. 26 In a recent article on best evidence to best practice, Grovi et al 27 state, "Even if doctors are aware of the evidence and are willing to change, to alter pattern of care is difficult[horizontal ellipsis]." The researchers identify the following steps in trying to change or implement a new practice:

 

* involve relevant people

 

* develop a proposal

 

* study the main difficulties in achieving change

 

* select a set of strategies/measures

 

* develop a budget.

 

 

Wound care professionals can make an impact on MRSA/VRSA in their specialized population. Accept the challenge and make it a priority in 2004.

 

Acknowledgment:

The author wishes to acknowledge the help of Arlene Shubin in the preparation of this manuscript.

 

References

 

1. Farr BM, Jarvis WR. Would active surveillance cultures help combat healthcare-related methicillin-resistant Staphylococcus aureus infections? Infect Control Hosp Epidemiol 2002;23(2):65-8. [Context Link]

 

2. Benner EJ, Kayser FH. Growing clinical significance of methicillin-resistant Staphylococcus aureus. Lancet 1968;ii:741-4. [Context Link]

 

3. Barrett FF, McGehee RF Jr, Finland M. Methicillin-resistant Staphylococcus aureus at Boston City Hospital: bacteriologic and epidemiologic observations. N Engl J Med 1968;279:441-8. [Context Link]

 

4. National Noscomial Infections Surveillance System Report, data summary from January 1992 through June 2003, issued August 2003. Am J Infect Control 2003;31:481-98. [Context Link]

 

5. Craven DE, Rixinger AI, Goularte TA, McCabe WR. Methicillin-resistant Staphylococcus aureus bacteremia linked to intravenous drug users using a "shooting gallery." Am J Med 1986;80:770-6. [Context Link]

 

6. Saravolatz LD, Pohlod DJ, Arking LM. Community-acquired methicillin-resistant Staphylococcus aureus infections: a new source for nosocomial outbreaks. Ann Intern Med 1982;97:325-9. [Context Link]

 

7. Suggs AH, Maranan MC, Boyle-Vavra S, Daum RS. Methicillin-resistant and borderline resistant asymptomatic Staphylococcus aureus colonization in children without identifiable risk factors. Pediatr Infect Dis J 1999;18:410-4. [Context Link]

 

8. Gorak EJ, Yamada SM, Brown JD. Community-acquired methicillin-resistant Staphylococcus aureus in hospitalized adults and children without known risk factors. Clin Infect Dis 1999; 29:797-800. [Context Link]

 

9. Herold BC, Immergluck LS, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998;279:593-8. [Context Link]

 

10. Layton MC, Heirholzer WJ Jr, Patterson JE. The evolving epidemiology of methicillin-resistant Staphylococcus aureus at a university hospital. Infect Control Hosp Epidemiol 1995:16:12-7. [Context Link]

 

11. Moreno F, Crisp C, Jorgensen JH, Patterson JE. Methicillin-resistant Staphylococcus aureus as a community organism. Clin Infect Dis 1995;21:1308-12. [Context Link]

 

12. Kallen AJ, Driscoll TJ, Thornton S, Olson PE, Wallace MR. Increase in community-acquired methicillin-resistant Staphylococcus aureus at a naval medical center. Infect Control Hosp Epidemiol 2000;21:223-6. [Context Link]

 

13. Goetz A, Posey K, Fleming J, et al. Methicillin-resistant Staphylococcus aureus in the community: a hospital-based study. Infect Control Hosp Epidemiol 1999;20:689-91. [Context Link]

 

14. Shopsin B, Mathema B, Martinez J, et al. Prevalence of methicillin-resistant and methicillin-susceptible Staphylococcus aureus in the community. J Infect Dis 2000; 182:359-62. [Context Link]

 

15. Jernigan J, Pullen A, Flowers L, Bell M, Jarvis WR. Prevalence of and risk factors for colonization with methicillin-resistant Staphylococcus aureus at the time of hospital admission. Infect Control Hop Epidemiol 2003;24:409-14. [Context Link]

 

16. Sanford MD, Widmer AF, Bale MJ, Jones RN, Wenzel RP. Efficient detection and long-term persistence of the carriage of methicillin-resistant Staphylococcus aureus. Clin Infect Dis 1994;19:1123-28. [Context Link]

 

17. Troillet N, Carmeli Y, Samore MH, et al. Carriage of methicillin-resistant Staphylococcus aureus at hospital admission. Infect Control Hosp Epidemiol 1998;19:181-5. [Context Link]

 

18. Samad A, Banerjee D, Carbarns N, Ghosh S. Prevalence of methicillin-resistant Staphylococcus aureus colonization in surgical patients, on admission to a Welsh hospital. J Hosp Infect 2002;51:43-6. [Context Link]

 

19. Adcock PM, Pastor P, Medley F, Patterson JE, Murphy TV. Methicillin-resistant Staphylococcus aureus in two child care centers. J Infect Dis 1998;178:577-80. [Context Link]

 

20. Groom A, Wolsey D, Naimi T, et al. Community-acquired methicillin-resistant Staphylococcus aureus in a rural American Indian community. JAMA 2001;286:1201-5. [Context Link]

 

21. Lindenmayer JM, Schoenfeld S, O'Grady R, Carney JK. Methicillin-resistant Staphylococcus aureus in a high school wrestling team and the surrounding community. Arch Intern Med 1998;158:895-9. [Context Link]

 

22. Mylotte JM, Graham R, Kahler L, Young L, Goodnough S. Epidemiology of nosocomial infection and resistant organsms in patients admitted for the first time to an acute rehabilitation unit. Clin Infect Dis 2003;36:281-5. [Context Link]

 

23. Manian F, Senkel D, Zack J, Meyer L. Routine screening for methicillin-resistant Staphylococcus aureus among patients newly admitted to an acute rehabilitation unit. Infect Control Hosp Epidemiol 2002;23:516-9. [Context Link]

 

24. Huang SS, Platt R. Risk of methicillin-resistant Staphylococcus aureus infection after previous infection or colonization. Clin Infect Dis 2003;36:281-5. [Context Link]

 

25. Fridkin SK, Hageman J, McDougal LK, et al. Epidemiological and microbiological characterization of infections caused by Staphylococcus aureus with reduced susceptibility to vancomycin, United States, 1997-2001. Clin Infect Dis 2003;36:429-39. [Context Link]

 

26. Bodenheimer T. The American health care system; the movement for improved quality in health care. N Engl J Med 1999;340:488-92. [Context Link]

 

27. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003;362:1225-30. [Context Link]