MRSA Infection

Dr. Srishti GuptaMBBS

June 28, 2021

June 28, 2021

MRSA Infection
MRSA Infection

Methicillin-resistant staphylococcus aureus (MRSA) has evolved over time into a bacterial strain distinct from staphylococcus aureus by accruing genetic changes that allow it to secrete chemicals that render beta-lactam antibiotics like penicillins and cephalosporins invalid. Some staphylococcus aureus strains that are found to be sensitive to methicillin are called methicillin-susceptible staphylococcus aureus (MSSA). There are three essential factors that contribute to MRSA infection

Staphylococcus aureus: Staphylococcus aureus is a round spherical shaped bacteria that usually appear in clusters upon viewing with a microscope and is Gram-positive, which means it changes colour with the application of reagent in Gram staining. Gram-positive bacteria have a thicker peptidoglycan outer cell wall but are generally more susceptible to treatment with antibiotics than Gram-negative bacteria. Staphylococcus aureus is a facultative anaerobic bacteria; it can thrive even without the presence of oxygen. Hence, it is a common causative organism of pyogenic, or pus-filled, infections and abscesses. Skin infections are the most common infections caused by staphylococcus aureus but, bloodstream infections, abscesses, osteomyelitis (bone infection), pneumonia and endocarditis are also possible. Of all the common infection-causing bacteria, staphylococcus aureus is perhaps the most feared due to its potential to cause widespread infection and its rising antibiotic resistance. Staphylococcus aureus is transmitted through touch and contact with a person infected with the bacteria whether the person displays symptoms of infection or not, as with an asymptomatic carrier. Due to this route of transmission, staphylococcus aureus infections can easily be spread in the community and hospital settings where sick patients can pass on the bacteria to other patients with compromised immune systems (for example, HIV patients, cancer patients, post organ transplant patients or patients receiving immunosuppressive treatment).

Methicillin: Penicillins are a class of antibiotics that share a similar chemical structure composed of one or more beta-lactam rings. Once a revolutionary drug that brought the modern world out of the pre-antibiotic era of preventable early deaths caused by minor infections, today penicillin is plagued by the problem of growing resistance towards it by bacteria. As a product of evolution, bacteria today have developed chemicals that can render some antibiotics ineffective against them; this is called antibiotic resistance. Many common infection-causing bacteria have developed the ability to secrete an enzyme called beta-lactamase, which breaks down the beta-lactam ring of penicillin and makes it inert. Methicillin is an antibiotic drug that works against certain bacteria and belongs to the class of Penicillins. Unlike other older generation penicillins, methicillin is resistant to the action of bacterial beta-lactamase, which means it can act on, and kill, the bacteria even if it secretes beta-lactamase. The beta-lactamase resistant property of methicillin made it a very important and effective last-resort antibiotic. Even though once it was effective against bacteria like streptococcus and staphylococcus, today the rising antibiotic resistance in bacteria has rendered methicillin ineffective in most cases. Thus, methicillin-resistant staphylococcus aureus (MRSA) gives rise to a two-fold problem – a commonly transmissible bacteria causing serious infections that have stopped responding to commonly available and highly effective antibiotics.

Antibiotic resistance: When antibiotics are used unsparingly and spuriously, the problem of antibiotic resistance arises. Bacteria respond to constant exposure to antibiotics by evolving and developing genes that award them defence mechanisms, like chemicals that can break down antibiotics and render them ineffective. Although evolution is an expected outcome in all organisms, this development is sped up by the use of unnecessary and excessive antibiotics to a rate that cannot keep pace with the production of new antibiotics. Incorrect diagnoses or prescription of antibiotics without sensitivity testing leads to increased use of incorrect antibiotics, which in turn may kill off bacteria in the body responsive to the antibiotic but allow resistant bacteria to persist, multiply and eventually be transmitted in the community. A common example of misguided use of antibiotics is its use to treat the common cold, which is, in fact, caused by a virus.

(Read more: Viral infections)

Classification of MRSA infection

Owing to the intermingling of large numbers of patients with bacterial infections and those with weakened immune systems in hospitals, methicillin-resistant staphylococcus aureus (MRSA) infections started out as hospital-acquired methicillin-resistant staphylococcus aureus (HA-MRSA). Today, three different types of methicillin-resistant staphylococcus aureus (MRSA) infections are possible. Classification of methicillin-resistant staphylococcus aureus (MRSA) infections are as follows:

  • Hospital-acquired methicillin Resistant Staphylococcus Aureus (HA-MRSA) infections: Hospital-acquired methicillin-resistant staphylococcus aureus (HA-MRSA) infections are generally contracted in medical facilities like hospitals, clinics and nursing homes. Bacteria may spread from open wounds or contaminated surfaces of linen, indwelling tubes or hands. These infections tend to be more severe, especially if contracted by immunocompromised patients.
  • Community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA) infections: Community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA) infections spread from an infected person, symptomatic or asymptomatic, through direct contact, touch or shared items. Poor sanitation, hygiene and improper handwashing practices can be important contributing factors. These infections can be severe but usually present as skin infections.
  • Livestock acquired methicillin-resistant staphylococcus aureus (LA-MRSA) infections: The widespread use of antibiotics to keep poultry and livestock being reared for food disease-free has lead to the emergence of staphylococcus aureus strains resistant to methicillin in these animals. Livestock acquired methicillin-resistant staphylococcus aureus (LA-MRSA) infections are reported in humans who work animal husbandry jobs or handle meat. Most infections in humans affect the skin and soft tissue and are not as severe as hospital-acquired methicillin-resistant staphylococcus aureus (HA-MRSA) infections.
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Signs and symptoms of MRSA infection

The presentation of MRSA infection varies with the organ system the bacteria infects. While more serious infections can infect the bloodstream and become more widespread, involving distant organs, lungs, urinary tract and even bones, the most common presentation is that involving the skin. While methicillin-resistant staphylococcus aureus skin infection cannot be diagnosed by a simple visual inspection without laboratory testing, some features to note and report to a healthcare provider include:

  • Redness
  • Swelling
  • Tenderness and pain
  • Warm to the touch
  • Full of pus or other drainages
  • Accompanied by a fever
  • Skin presentation of methicillin-resistant staphylococcus aureus (MRSA) is often described as looking like a spider bite by many patients 

Other non-skin-related signs and symptoms of MRSA infection can sometimes include, but may not be limited to:

 

Risk factors of MRSA infection

Methicillin-resistant staphylococcus aureus (MRSA) bacteria can be acquired in various settings (hospitals, community or through livestock, amongst others) but certain factors increase the likelihood of infection further. Factors that can lead to methicillin-resistant staphylococcus aureus (MRSA) infection include:

  • Non-intact skin like abrasions or incisions can be potential sites or methicillin-resistant staphylococcus aureus (MRSA) infection
  • Receiving inpatient medical care at a medical facility
  • Patients having undergone surgery and in postoperative care
  • Medical devices inserted in one’s body like indwelling catheters or tubes
  • Weakened immune system due to: 
  • Living or working in crowded areas with poor sanitation, hygiene and ventilation
  • Activities that involve crowding, skin-to-skin contact and shared equipment or supplies
  • Working with livestock or poultry animals
  • Contact with a contaminated wound
  • Sharing personal items, such as towels or razors, that have touched infected skin
  • Intravenous drug abuse and sharing of needles

Diagnosis of MRSA infection

The diagnosis of methicillin-resistant staphylococcus aureus (MRSA) is not clinical but based on laboratory testing. However, the infection caused will be diagnosed clinically by the doctor. The doctor will begin by taking a detailed medical history from the patient, which will include an emphasis on past medical history, current or long term medications, symptoms and complaints. Additional information about living conditions, lifestyle practices and activities may also be sought. After taking a thorough medical history the doctor will proceed to conduct a comprehensive physical clinical examination of the patient. Radiological investigations can also help cement the diagnosis in some cases, like chest X-rays for lung infections. Some special laboratory investigations will be ordered to discern the causative organism of the infection and antibiotic sensitivity information.

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Tests for MRSA infection

The diagnosis of methicillin-resistant staphylococcus aureus (MRSA) can only be made after the bacteria is demonstrated in an appropriate sample collected from the patient.

  • Blood tests: 
    • Full blood count: A raised white blood cell count will indicate ongoing infection.
    • Blood culture and sensitivity testing: The bacteria in the bloodstream is identified and information on the antibiotics it is susceptible to is made available for apt treatment.
  • Urine tests: 
    • Urine dipstick: A rapid test that can indicate the presence of nitrites and leukocyte esterase, implying the presence of bacterial infection.
    • Urinalysis and urine routine microscopy: Pus cells and white blood cells may be present in urine in the case of a urinary tract infection (UTI).
    • Urine culture and sensitivity testing: The presence of bacterial infection can be confirmed. The bacteria in urine is identified and information on the antibiotics it is susceptible to is made available for apt treatment.
  • Sputum culture and sensitivity testing: When a chest infection is diagnosed or suspected, a sputum sample is collected and tested. The bacteria present in sputum is identified and information on the antibiotics it is susceptible to is made available for apt treatment.
  • Pus culture and sensitivity testing: In case of open pus-filled wounds or purulent skin infections, a swab is used to collect a pus sample. The bacteria present in the pus is identified and information on the antibiotics it is susceptible to is made available for treatment.

Management of MRSA infection

The mainstay of treatment is the prescription of an effective antibiotic against the bacteria.

  • Medical: The appropriate management of methicillin-resistant staphylococcus aureus (MRSA) infections is to treat with the antibiotic the causative bacteria is susceptible to on the basis of a laboratory report. Usually, hospital-acquired methicillin-resistant staphylococcus aureus infections tend to be more severe (eg. septicemia, pneumonia, etc.) and require intravenous antibiotics. Skin infections that are less severe may be managed by oral antibiotics instead.
  • Surgical: In cases of abscess formation, incision and drainage under anesthesia may be performed. Antibiotics, after sensitivity testing, are also given.

Prevention of MRSA infection

Following are some ways MRSA infection can be prevented.

  • Prevention of methicillin-resistant staphylococcus aureus (MRSA) infection: Spread of methicillin-resistant staphylococcus aureus (MRSA) can be prevented in hospitals and the community by:
    • Maintaining good hand and body hygiene. Regular hand washing and using hand sanitisers with at least 60% alcohol content when hand washing is not possible is important.
    • Keeping cuts, scrapes and wounds clean and covered until healed.
    • Avoiding sharing personal items such as towels and razors.
  • Prevention of antibiotic resistance: Antibiotic resistance has arisen due to poor practices of antibiotic use. Correcting wrongs can not only help impede the rise of antibiotic resistance in bacteria but, according to research, can also reverse it in some cases. Measures individuals can take to prevent antibiotic resistance include:
    • Only taking antibiotics when prescribed by a certified health professional
    • Never demanding antibiotics if the health worker says they are not needed
    • Always following a health worker’s advice when using antibiotics with respect to the dose and duration
    • Never sharing or using leftover antibiotics
    • Regular hand washing, avoiding close contact with sick people, practising safe sex and keeping vaccinations up to date
    • Preparing food hygienically, separating raw and cooked food, cooking thoroughly, keeping food at safe temperatures and using safe water and raw materials
    • Choosing foods (meats and poultry) that have been produced without the injudicious use of antibiotics
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