Screening for

MRSA
Dr.T.V.Rao MD

10/24/16

Dr.T.V.Rao MD @ ClinicalMicrobiology

What is MRSA?

MRSA is Staphylococcus aureus with resistance to a specific class of

antibiotics, penicillinase-resistant penicillin's.

MRSA stands for methicillin-resistant Staphylococcus aureus.

Staphylococcus aureus is the scientific name for the bacteria that cause
staph infections, including:
most frequently, skin and soft tissue infections, such as boils
deeper infections, including invasion of the bloodstream and spreading
around the body to cause serious, life threatening infections such as
septicemia, abscesses, meningitis and pneumonia

MRSA were first reported in 1961 in England.

It took only a few months from introduction of the first penicillinase-resistant
antibiotic to recognition of infections from MRSA.

What is MRSA? (cont.)

Clinically,

MRSA isnt particularly different than staph

without methicillin resistance.
Methicillin resistance by itself is not an added risk for the individual
having a staph infection.
Other antibiotics are still available to treat MRSA infections.

However,

MRSA is a concern to medical and public health

communities in general.
It represents a marked increase in antibiotic resistance in staphylococci.
Different antibiotics need to be used to treat and prevent it.
More expensive antibiotics, such as vancomycin, often have more side effects, and
increasing their use may result in additional antibiotic resistance in staphylococci,
potentially rendering them in the future very difficult to treat.

Colonization Sites
Infectio
ns

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Dr.T.V.Rao MD @ MRSA

What are the different kinds of strains of

MRSA?

MRSA

developed from methicillin-susceptible staph because

methicillin and its relatives, such as oxacillin, were widely
used and selected for resistant strains.

This

selection process has happened at least several times in

the last 10-30 years.
In the 1960s, strains of MRSA emerged in hospitals.
Hospital strains tend to be resistant to additional antibiotics, and
often cause bloodstream infections.

In the 1990s, new strains of MRSA emerged in the

community.
Community strains tend to produce toxins that lead to skin
infections and abscesses but are less often resistant to other
antibiotics.

HOW WE DEFINE MRSA IN OUR

LABORATORY
Strains that are oxacillin and

methicillin resistant, historically

termed methicillin-resistant S.
aureus (MRSA), and are
resistant to all -lactam agents,
including cephalosporins and
carbapenems, although they
may be susceptible to the
newest class of MRSA-active
cephalosporins (e.g,
ceftaroline).
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Dr.T.V.Rao MD @ ClinicalMicrobiology

MRSA and Drug Resistance

10/24/16

Strains of MRSA causing

healthcare-associated
infections often are
multiply resistant to other
commonly used
antimicrobial agents,
including erythromycin,
clindamycin,
fluoroquinolones and
tetracycline,

Dr.T.V.Rao MD @ ClinicalMicrobiology

Community associated
Staphylococcus
Strains causing
communityassociated
infections are
often resistant
only to -lactam
agents and
erythromycin,
may be resistant
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Dr.T.V.Rao MD @ ClinicalMicrobiology

Rationale for MRSA

screening

Colonized patients constitute the main reservoir

for nosocomial transmission
Colonized patients are only detected by active
surveillance sampling of muco-cutaneous swabs
Hospitalized patients carrying MRSA are at
high risk to develop a MRSA infection
High mortality (RR 1.9 vs MSSA, RR > 10 vs no
infection) and prolonged hospital stay (2-13 days)
is associated with MRSA infections

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Dr.T.V.Rao MD @ ClinicalMicrobiology

Classification of Risk Factors for

MRSA Infections
There are certain factors that increase the risk of a
person contracting MRSA .

These factors include:

have previously had MRSA
are coming from a high risk environment (e.g. hospital or nursing
home)
1

patients with a chronic wound, e.g. Leg ulcers

2indwelling medical
devices e.g. catheter
3 being admitted as an inpatient in another hospital
within the last 6 months drug therapy that
reduces the auto-immune response.
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Potential benefits for

rapid MRSA identification
Patient care Early appropriate treatment
with improve clinical outcome Reduced
empirical use of glycopeptides
Infection control Early MRSA
isolation/cohorting Decrease in
nosocomial transmission rate Decrease in
MRSA morbidity and mortality Cost saving
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Shorter patient stay

Dr.T.V.Rao MD @ ClinicalMicrobiology

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Whoshouldbe screened for

MRSA?
NHS
Guidelines
MRSA screening is usually carried out inpeople who need to be
admitted to hospital for planned or emergency care.
In particular, it's recommended for certain groups at the
highest risk of becoming infected with MRSA while they're in
hospital. These include:
People who have been infected or colonised (carry the bacteria
on their skin) with MRSA previously
People being admitted to certain "high-risk" hospital units
including surgery, cancer, kidney and trauma units
People who aren't staying in hospital overnight don't usually
need to be routinely screened.
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Collecting Specimens for

Detecting MRSA
Patients were
swabbed with
rayon-tipped
swabs on
admission at 4
body sites:
nostrils,
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How should clinical laboratories

test for MRSA
In addition to broth microdultion testing,
the Clinical and Laboratory Standards
Institute (CLSI), recommends the
cefoxitin disk screen test, the latex
agglutination test for PBP2a, or a plate
containing 6 g/ml of oxacillin in MuellerHinton agar supplemented with 4% NaCl as
alternative methods of testing for MRSA..
In addition, there are now several
FDA-approved selective chromogenic
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Dr.T.V.Rao MD @ ClinicalMicrobiology

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Chromogenic Agars help in

Identification
In addition, there
are now several
FDA-approved
selective
chromogenic agars
that can be used
for MRSA detection
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Why are oxacillin and cefoxitin

tested instead of methicillin?
First, methicillin is no longer
commercially available in the
United States. Second, oxacillin
maintains its activity during
storage better than methicillin
and is more likely to detect
heteroresistant strains. However,
cefoxitin is an even better
inducer of the mecA gene, and
tests using cefoxitin give
more reproducible and
accurate results than tests
with oxacillin.
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Dr.T.V.Rao MD @ ClinicalMicrobiology

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If oxacillin and cefoxitin are tested, why are

the isolates called MRSA instead of ORSA?
When resistance was first described in 1961, methicillin was used
to test and treat infections caused by S. aureus. However,
oxacillin, which is in the same class of drugs as methicillin, was
chosen as the agent of choice for testing staphylococci in the early
1990s, and this was modified to include cefoxitin later. The
acronym MRSA is still used by many to describe these isolates
because of its historic role.
Ref 1 CLSI. 2013. Performance standards for antimicrobial
susceptibility testing. CLSI approved standard M100-S23. Clinical
and Laboratory Standards Institute, Wayne, PA.
2Bannerman, TL. 2003. Staphylococcus, Micrococcus and other
catalase-positive cocci that grow aerobically. In P.R
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How is the mecA gene involved in

the mechanism of resistance?
Staphylococcal
resistance to
oxacillin/methicillin
occurs when an isolate
produces an altered
penicillin-binding
protein, PBP2a, which is
encoded by the mecA
gene. The variant
penicillin-binding protein
binds beta-lactams with
lower
avidity, whichDr.T.V.Rao MD @ ClinicalMicrobiology
10/24/16
results in resistance to

18

Are there additional tests to

detect oxacillin/methicillin
resistance?
Nucleic acid amplification tests,
such as the polymerase chain
reaction (PCR), can be used to
detect the mecA gene, is the
most common gene that
mediates oxacillin resistance in
staphylococci. However, mecA
PCR tests will not detect
novel resistance
mechanisms such as mecC
or uncommon phenotypes
such as borderline-resistant
oxacillin resistance.

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Dr.T.V.Rao MD @ ClinicalMicrobiology

19

Can Healthy People Get MRSA?

MRSA skin infections are
showing up more frequently in
healthy people, with none of the
usual risks factors. This type of
MRSA - called communityassociated MRSA (CA MRSA) - has
been reported among athletes,
prisoners, and military recruits.
Outbreaks have been seen at
schools, gyms, day care centres
and other places where people
share close quarters.
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Who is at risk for MRSA?

those most at risk:
Spend a lot of time in
crowded places such as
hospitals, schools or rooms
Share sports
equipment
Share personal hygiene items
Play contact sports
Overuse or
misuse antibiotics
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Dr.T.V.Rao MD @ ClinicalMicrobiology

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What do you understand by

Vancomycin Resistance

10/24/16

Since 1996, MRSA strains

with decreased
susceptibility to
vancomycin (minimum
inhibitory concentration
[MIC], 4 8 g/ml) and
strains fully resistant to
vancomycin (MIC 32
g/ml) have been
reported.

Dr.T.V.Rao MD @ ClinicalMicrobiology

22

How can people protect themselves from

MRSA?
Collective

public vigilance and demands for better application

of infection control standards to reduce healthcare-associated
MRSA

In

the hospital

Hand washing before and after seeing each patient

Care of IV lines
At

the personal level

Wash hands or other body surfaces, especially after skin-to-skin

contact with other people and with healthcare settings
Avoid sharing potentially contaminated items, such as towels,
unwashed clothing
Clean and cover abrasions/cuts as soon after they occur as possible
Seek healthcare consultation at the first signs of possible infection

Decolonization
Decolonization entails treatment of
persons colonized with a specific MDRO,
usually MRSA, to eradicate carriage of
that organism However, decolonization of
persons carrying MRSA in their nares has
proved possible with several regimens
that include topical mupirocin alone or in
combination with orally administered
antibiotics (e.g., rifampin in combination

Can Chemical baths help in

reducing MRSA incidence
In one report, a 3day regimen of
baths with
povidone-iodine and
nasal therapy with
mupirocin resulted
in eradication of
nasal MRSA
colonization(304).
These and other
methods of MRSA
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WHAT REALLY WE NEED TODAY

Always washingyour hands after using the toilet
or commode (many hospitals now routinely offer
hand wipes)
Always washing your hands or cleaning them
with a hand wipe immediately before and after
eating a meal
Following any advice you're given about wound
care and devices that could lead to infection
(such as urinary catheters)
Reporting any unclean toilet or bathroom
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Dr.T.V.Rao MD @ MRSA

General Hygiene too Matters

The hospital
environment,including
floors, toilets and
beds,should be kept as
clean and dry as possible.
Patients with a known or
suspected MRSA infection
should be isolated.
Patients should onlybe
transferred between
wards when it is strictly
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Dr.T.V.Rao MD @ MRSA
necessary.

In spite of Many Developments in Control of MRSA

HAND WASHING STILL BEST EASIER OPTION

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References
What are the susceptibility patterns of clinical S. aureus
isolates? CDC resources Laboratory Testing for MRSA
2MDRO Prevention and Control Healthcare Infection
Control Practices Advisory Committee (HICPAC) CDC

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Program Created by Dr.T.V.Rao MD

for Medical professionals for
improving awareness on Hospital
Associated Infection with spread of
MRSA
Email
doctortvrao@gmail

10/24/16

Dr.T.V.Rao MD @ ClinicalMicrobiology

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