In this section, you'll find information on MRSA for healthcare providers such as physicians, nurses, public health professionals and others practicing in community-based settings in Massachusetts.

What is MRSA?

MRSA is a kind of Staphylococcus aureus ("staph") bacterium that is resistant to beta-lactam antibiotics, including methicillin, oxacillin, penicillin and amoxicillin. It is often resistant to many other antibiotics as well.

For general information about MRSA and Staphylococcus aureus for patients, please see the resource list below.

Why is MRSA a problem for healthcare providers?

  • In Massachusetts and elsewhere throughout the country, MRSA infections are becoming more common.
  • Identifying a MRSA infection can be difficult because the symptoms of MRSA infection are similar to those of other skin infections. MRSA can only be diagnosed by culture and laboratory testing. The laboratory will also perform antibiotic susceptibility testing.
  • Misdiagnosis or delayed diagnosis of MRSA infection can result in delayed treatment and more serious complications.
  • MRSA is part of a larger problem of antibiotic resistance. In the long term, Staphylococcus aureus may become resistant to many more antibiotics. For this reason it is important that healthcare providers diagnose MRSA early and accurately, prescribe appropriate antibiotics if needed, and direct patients to complete the full course of antibiotics as prescribed. At the same time, healthcare providers should be cautious about the unnecessary use of antibiotics, which can contribute to the problem of antibiotic resistance.

What is the history of MRSA and Antibiotic Resistance?

Not long after penicillin was in wide use, it was recognized that some staphylococci were less sensitive to penicillin than other staphylococci. As early as the mid-1940s, Alexander Fleming, the British scientist who is often credited with the discovery of penicillin, warned health care workers about overuse and misuse of antibiotics as a contributor to the development of antibiotic resistance.

MRSA was first discovered several decades ago in hospitals and other healthcare settings across the country. Infection with MRSA presented in the form of surgical wound infections, urinary tract infections, bloodstream infections and pneumonia.

In recent years, MRSA infections are being diagnosed with increased frequency in people who have had no contact with healthcare facilities and are otherwise healthy.

Are there different types of MRSA infections?

In the past, the term "Healthcare-Associated MRSA" (HA-MRSA) has been used to describe MRSA infections acquired in healthcare settings. The term "Community-Associated MRSA" (CA-MRSA) has been used to describe MRSA infections that occur in the community in people who have not had contact with a healthcare setting.

There are genetic differences between HA-MRSA and CA-MRSA, which may result in differing susceptibility to certain antibiotics. However, both HA-MRSA and CA-MRSA infections have the same symptoms, and are controlled and prevented in the same manner. Given the rise in CA-MRSA infections, the distinction in terms is no longer considered to be as important as it once was.

Who is at increased risk for getting MRSA infections in the community?

Outbreaks of illness due to MRSA are seen most commonly among particular populations: inmates in correctional facilities (1), athletes participating in team sports (2), neonates (3), military recruits (4), and Native Americans and Pacific Islanders (5,6), among others. When comparing patients with CA-MRSA to those with HA-MRSA, a study in Minnesota showed that CA-MRSA patients were more likely to be non-white, younger and have lower median income. Among pediatric cases, many had an underlying dermatologic condition. The majority of adult CA-MRSA cases (76%) had an underlying medical condition (7).

In Massachusetts , we have received reports of possible CA-MRSA infection clusters in correctional facilities, among sports teams, among men who have sex with men, and at colleges.

Factors that have been associated with the spread of MRSA skin infections include close skin-to-skin contact, openings in the skin such as cuts or abrasions, contaminated items and surfaces, crowded living conditions, and poor hygiene.

Review scientific publications reporting past outbreaks of MRSA in the community.

Are my patients at higher risk for MRSA infection?

MRSA infections sometimes occur among previously healthy persons with no identifiable risk factors. However, identifying patients at increased risk for MRSA can guide empiric antibiotic selection and avoid use of agents ineffective against MRSA (particularly cephalosporins).

Photo of MRSA infection on wrist and hand.

Risk factors that should increase the level of suspicion for MRSA:

  • History of MRSA infection or colonization
  • History in the past year of:
    • Hospitalization
    • Admission to a long term care facility (nursing home, skilled nursing, or hospice)
    • Dialysis and end-stage renal disease
    • Diabetes mellitus
    • Surgery
  • Permanent indwelling catheters or medical devices that pass through the skin into the body
  • Injection drug use
  • Recent and/or frequent antibiotic use
  • Close contact with someone known to be infected or colonized with MRSA
  • Recurrent skin disease
  • Crowded living conditions (e.g., homeless shelters)
  • Incarceration
  • Infection among sports participants who have:
    • Skin-to-skin contact
    • Pre-existing skin damage
    • Shared clothing and/or equipment

What are the clinical features of MRSA infection?

MRSA most often presents as skin or soft tissue infection, such as a boil or abscess. Patients frequently suspect a "spider bite." The involved site is red, swollen, and painful and may have pus or other drainage. Staph infections also can cause more serious infections, such as blood stream infections or pneumonia; with symptoms of shortness of breath, fever, and chills.

Staph infection on the face.   Staph Infection #5

How is MRSA diagnosed?

To diagnose MRSA, the CDC recommends obtaining a culture from the infection site and sending it to the laboratory.

  • Skin Infection: Obtain either a small biopsy of skin or drainage from the infected site. A culture of a skin lesion is especially useful in recurrent or persistent cases, in cases of antibiotic failure, and in cases that present with advanced or aggressive infections.
  • Pneumonia: Obtain a sputum culture (expectorated purulent sputum, respiratory lavage, or bronchoscopy).
  • Bloodstream Infection: Obtain blood cultures using aseptic techniques.
  • Urinary Infection: Obtain urine cultures using aseptic techniques.

If staph bacteria are isolated, the organism should be tested to determine which antibiotics are effective for treatment .

How are MRSA infections treated?

Like other staph infections, many MRSA infections are best treated with good wound and skin care: keeping the area clean and dry, washing hands after caring for the area, carefully disposing of any bandages, and allowing the body to heal. Sometimes staph skin infections may be treated by incision and drainage, depending on severity. Antibiotic treatment, if indicated, should be guided by the susceptibility patterns of the organism in the setting or area.

Image of a skin staph infection.

An important part of treatment is providing patient education about good wound care, taking all antibiotics as prescribed, and the need for follow-up visits, if necessary. Download and print helpful reminders about caring for MRSA infections at home (PDF) pdf format of mrsa-helpful-reminders.pdf
rtf format of mrsa-helpful-reminders.rtf .

Treatment is not generally recommended for people who are colonized with (but have no infection resulting from) MRSA.

What follow-up care is necessary after treatment has begun?

The provider should monitor the patient's response to therapy, and encourage the patient to contact the office with questions as the treatment progresses.

What are the reporting requirements for MRSA?

Individual cases of MRSA are currently not reportable to the Massachusetts Department of Public Health (MDPH). However, please contact MDPH at (617) 983-6800 if you suspect a cluster of cases.

In addition, please review the Massachusetts Department of Public Health HIPAA FAQs for more information on privacy and reporting.

How can staph/MRSA infections be prevented in the healthcare setting?

As with other infectious diseases, basic infection control practices should be followed:

  • Practice hand hygiene . Encourage patients to practice proper handwashing as well.
  • Use contact precautions for ALL patients with open or draining Staphylococcus aureus skin and soft tissue infections (SSTI) and all patients known to be infected with MRSA.

The standard components of contact precautions are:

  • Examine patients with MRSA in a private room.
  • Wear gloves (clean nonsterile gloves are adequate) when providing care for patients.
  • Change gloves after contact with infective material that may contain high concentrations of microorganisms (e.g., wound drainage or dressings).
  • Remove gloves before leaving the patient's room and wash hands immediately. After glove removal and handwashing, do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients and environments.
  • Wear a gown when providing care if there will be substantial contact with the patient's wound. Remove the gown before leaving the examination room.
  • Ensure that patient-care items and potentially contaminated surfaces are cleaned and disinfected after use.
  • Select EPA-registered disinfectants, if available, and use them in accordance with the manufacturer's instructions.
  • Clean noncritical medical equipment surfaces with a detergent/disinfectant.
  • Do not use alcohol to disinfect large environmental surfaces.
  • Use barrier protective coverings as appropriate for noncritical surfaces that are 1) touched frequently with gloved hands during the delivery of patient care; 2) likely to become contaminated with blood or body substances; or 3) difficult to clean.
  • Keep housekeeping surfaces (e.g., floors, walls, tabletops) visibly clean on a regular basis and clean up spills promptly.

For additional information on infection control, see:

What information on MRSA is available for my patients?

References

(1) Methicillin-resistant Staphylococcus aureus infections in correctional facilities--- Georgia , California , and Texas , 2001-2003. MMWR Morb Mortal Wkly Rep 2003; 52(41):992-996.

(2) Begier EM, Frenette K, Barrett NL et al. A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns. Clin Infect Dis 2004; 39(10):1446-1453.

(3) CDC. Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus - Minnesota and North Dakota, 1997-1999. Morbidity and Mortality Weekly Report 1999; 48(32):707-710.

(4) Campbell KM, Vaughn AF, Russell KL et al. Risk factors for community associated methicillin-resistant Staphylococcus aureus infections in an outbreak of disease among military trainees in San Diego, California, in 2002. J Clin Microbiol 2004; 42(9):4050-4053.

(5) Stemper ME, Shukla SK , Reed KD. Emergence and spread of community associated methicillin-resistant Staphylococcus aureus in rural Wisconsin , 1989 to 1999. J Clin Microbiol 2004; 42(12):5673-5680.

(6) Community-associated methicillin-resistant Staphylococcus aureus infections in Pacific Islanders-- Hawaii , 2001-2003. MMWR Morb Mortal Wkly Rep 2004; 53 (33):767-770.

(7) LeDell KH, Como-Sabetti K, Lynfield R. The changing epidemiology of MRSA: Emergence of community-associated MRSA in Minnesota . Contagion 2004; 1 (2):77-84.

External Links

For more information about MRSA, visit:

Infection Control

Guidelines

Articles
  • CDC. "Four Pediatric Deaths for Community-Acquired Methicillin-Resistant Staphylococcus aureus- Minnesota and North Dakota, 1997-1999." MMWR. August 20, 1999.
    www.cdc.gov/mmwr/preview/mmwrhtml/mm4832a2.htm
  • Collignon P, Nimmo GR, Gottlieb T, Gosbell IB. " Staphylococcus aureus bacteremia, Australia ." Emerging Infectectious Diseases. April 2005.
    wwwnc.cdc.gov/eid/article/11/4/04-0772_article
  • Harbarth S, François P, Schrenzel J, Fankhauser-Rodriquez C, et al. "Community-associated Methicillin-resistant Staphylococcus aureus, Switzerland." Emerging Infectious Diseases. Jun 2005.
    wwwnc.cdc.gov/eid/content/11/6/contents.htm
  • Ma XX, Galiana A, et al. "Community-acquired Methicillin-resistant Staphylococcus aureus, Uruguay ." Emerging Infectious Diseases. Jun 2005.
    wwwnc.cdc.gov/eid/content/11/6/contents.htm
  • Naimi, Timothy, Kathleen H. LeDell, David J. Boxrud, et al. "Epidemiology and Clonality of Community-Acquired Methicillin-Resistant staphylococcus aureus in Minnesota , 1996-1998." Clinical Infectious Diseases. 2001; 33:990-996.

This information is provided by Epidemiology Program within the Department of Public Health.