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Methicillin-Resistant Staphylococcus aureus

      Managed care. Malpractice. Malingering. Medicine might be more marvelous minus this medley of “m”s. And now: MRSA. Methicillin-resistant Staphylococcus aureus. Mmmm ….
      Michael Pollan, bestselling author and professor of journalism at the University of California, Berkeley, where he is also director of the Knight Program in Science and Environmental Journalism, reported in the December 16, 2007 The New York Times Magazine that “MRSA, the very scary antibiotic-resistant strain of Staphylococcus bacteria … is now killing more Americans each year than AIDS—100,000 infections leading to 19,000 deaths in 2005, according to estimates in The Journal of the American Medical Association. For years now, drug-resistant staph infections have been a problem in hospitals, where the heavy use of antibiotics can create resistant strains of bacteria. It's Evolution 101: the drugs kill off all but the tiny handful of microbes that, by dint of a chance mutation, possess genes allowing them to withstand the onslaught; these hardy survivors then get to work building a drug-resistant superrace. The methicillin-resistant staph that first emerged in hospitals as early as the 1960s posed a threat mostly to elderly patients. But a new and even more virulent strain—called ‘community-acquired MRSA'—is now killing young and otherwise healthy people who haven't set foot in a hospital. No one is yet sure how or where this strain evolved, but it is sufficiently different from the hospital-bred strains to have some researchers looking elsewhere for its origin.”
      • Pollan M.
      The way we live now: Our decrepit food factories. The New York Times Magazine December 16, 2007.
      Also as reviewed in The New York Times,
      • Wener K.
      Health Guide: MRSA infection. The New York Times Health Guide Reviewed November 9, 2005.
      “MRSA infection is an infection with a strain of Staphylococcus aureus bacteria that is resistant to antibiotics known as beta-lactams. These antibiotics include methicillin, amoxicillin, and penicillin. Staphylococcus aureus (‘staph') are common bacteria that normally live on the skin. The bacteria also live harmlessly in the nasal passages of roughly 30% of the U.S. population. Staph can cause infection when they enter the skin through a cut or sore. Infection can also occur when the bacteria move inside of the body through a catheter or breathing tube. The infection can be minor and local (for example, a pimple), or more serious.
      “Most staph infections occur in people with weak immune systems, usually patients in hospitals and long-term care facilities. MRSA infections in hospitalized patients are known as healthcare-associated MRSA (HA-MRSA). People who have been hospitalized or had surgery within the past year are at high risk for HA-MRSA. People receiving certain treatments, such as dialysis, are also at high risk. MRSA bacteria account for a large percentage of hospital-acquired staph infections.
      • Wener K.
      Health Guide: MRSA infection. The New York Times Health Guide Reviewed November 9, 2005.
      “Over the past several years, MRSA infections in people not considered high-risk have increased. These infections, known as community-associated MRSA (CA-MRSA), occur in otherwise healthy people who have no history of hospitalization in the last year. Many such infections have occurred among athletes who share equipment or personal items (such as towels or razors) and children in daycare facilities.”
      • Wener K.
      Health Guide: MRSA infection. The New York Times Health Guide Reviewed November 9, 2005.
      Notably, “Few antibiotics are available to treat more serious MRSA infections. These include vancomycin (Vancocin, Vancoled), trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS), and linezolid (Zyvox).”
      • Wener K.
      Health Guide: MRSA infection. The New York Times Health Guide Reviewed November 9, 2005.
      Worse, in 2008, news of a new, multidrug-resistant strain of CA-MRSA was reported in the New York Times.
      • Altman L.K.
      New bacteria strain is striking gay men. The New York Times January 15, 2008.
      Citing a study reported in the Annals of Internal Medicine,
      • Diep B.A.
      • Chambers H.F.
      • Graber C.J.
      Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men.
      The Times reports that “the authors warned that unless microbiology laboratories were able to identify the strain and doctors prescribed the proper antibiotic therapy, the infection could soon spread and become a wider threat.”
      • Altman L.K.
      New bacteria strain is striking gay men. The New York Times January 15, 2008.
      Again, notably, “A single clone of community-associated MRSA, USA300, was not seen before 2000 but is now widely disseminated in 38 U.S. states, Canada, and 9 European Union countries and can cause unusually severe human diseases, including necrotizing fasciitis, sepsis, endocarditis, and pneumonia. Infections occur predominantly among healthy, community-dwelling persons lacking traditional risk factors for MRSA. Whereas hospital-associated MRSA strains are resistant to multiple antimicrobial classes, USA300 and other community-associated MRSA strains are typically resistant to β-lactams and 1 or 2 other drug classes … (however) a multidrug-resistant USA300 (has) accumulated multiple resistance genes, rendering it resistant to β-lactams, fluoroquinolones, tetracycline, macrolide, clindamycin, and mupirocin.”
      • Diep B.A.
      • Chambers H.F.
      • Graber C.J.
      Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men.
      While bacterial resistance to antibiotics is a problem well know to readers of Arthroscopy, we find the epidemic of MRSA to be of particular clinical concern. Readers should thus note, in the current issue, the report of “MRSA-Induced Septic Arthritis After Anterior Cruciate Ligament Reconstruction,” by Kurokouchi et al.
      • Kurokouchi K.
      • Takahashi S.
      • Yamada T.
      • Yamamoto H.
      Methicillin-resistant Staphylococcus aureus–induced septic arthritis after anterior cruciate ligament reconstruction.
      To the authors' knowledge, it is the first report of this complication in the English-language literature. Readers should especially note that, in contrast to the typical clinical course of joint sepsis after ACL reconstruction—resolution of sepsis with graft salvage when arthroscopic lavage and debridement and antibiotic treatment is initiated within 1 week after index surgery—in the reported case, multiple operations, graft and hardware removal, and administration of antibiotics for over a month were required until C-reactive protein levels “became negative.”
      Based on the reports from the lay press,
      • Pollan M.
      The way we live now: Our decrepit food factories. The New York Times Magazine December 16, 2007.
      • Wener K.
      Health Guide: MRSA infection. The New York Times Health Guide Reviewed November 9, 2005.
      • Altman L.K.
      New bacteria strain is striking gay men. The New York Times January 15, 2008.
      the internal medicine literature,
      • Diep B.A.
      • Chambers H.F.
      • Graber C.J.
      Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men.
      and our own journal,
      • Kurokouchi K.
      • Takahashi S.
      • Yamada T.
      • Yamamoto H.
      Methicillin-resistant Staphylococcus aureus–induced septic arthritis after anterior cruciate ligament reconstruction.
      Arthroscopy readers are cautioned to have a heightened index of suspicion for MRSA as a potential cause of joint or systemic sepsis. Risk factors for HA-MRSA and CA-MRSA have been recently reviewed in the Journal of the American Academy of Orthopaedic Surgeons
      • Marcotte A.
      • Trzeciak M.
      Community-acquired methicillin-resistant Staphylococcus aureus: An emerging pathogen in orthopaedics.
      and are summarized in Table 1.
      Table 1Risk Factors for MRSA
      HA-MRSA
       Hospitalization, surgery, dialysis, or residence in a long-term care facility within 1 year
       Permanent indwelling catheter or percutaneous medical device
       Previous MRSA
       Proximity to or contact with a patient colonized or infected with MRSA
       Recent antimicrobial therapy
      CA-MRSA
       Athletes in contact sports (e.g., basketball, fencing, football, rugby, volleyball, weightlifting, wrestling)
       Children in day care
       Homeless persons
       Intravenous drug users
       Men who have sex with men
       Military recruits
       Alaskan natives
       Native Americans
       Pacific Islanders
       Prison inmates
       Antibiotic use within the preceding year
       Close, crowded living conditions
       Compromised skin integrity
       Contact with contaminated surfaces (e.g., wrestling mats)
       Frequent skin-to-skin contact
       Shared items
       Suboptimal cleanliness
      Data from Marcotte et al.
      • Marcotte A.
      • Trzeciak M.
      Community-acquired methicillin-resistant Staphylococcus aureus: An emerging pathogen in orthopaedics.
      If MRSA is suspected, readers should notify their institutional microbiology laboratory of the concern with a goal of allowing the laboratory to more rapidly identify the specific bacterial strain and sensitivity so that proper antibiotic therapy can be prescribed. Pending such identification, prophylactic implementation of antimicrobial agents that will specifically cover MRSA is recommended
      • Marcotte A.
      • Trzeciak M.
      Community-acquired methicillin-resistant Staphylococcus aureus: An emerging pathogen in orthopaedics.
      in consultation with the pharmacy, the microbiology laboratory, and infectious disease, internal medicine, and/or primary care services. In addition, measures recommended to control MRSA infections in hospital and elective surgical settings include written MRSA standards, cohort nursing, nonselective screening of all admissions to orthopaedic wards, screening and decolonization of all patients having elective orthopedic procedures (especially those including prosthetic implants), use of polymerase chain reaction as a diagnostic tool, ring-fencing of beds, separate wound-dressing rooms for each ward, signal-colored isolation gowns and storage carts facilitating the use of separate supplies for patients with MRSA, intensified surveillance and feedback of MRSA data, “flagging” of formerly positive MRSA patients, gendine antiseptic dye coating of orthopaedic implants, and perioperative prophylaxis using nasal mupirocin and topical triclosan.
      • Hassan K.
      • Koh C.
      • Karunaratne D.
      • Hughes C.
      • Giles S.
      Financial implications of plans to combat methicillin-resistant Staphylococcus aureus (MRSA) in an orthopaedic department.
      • Trautmann M.
      • Pollitt A.
      • Loh U.
      • et al.
      Implementation of an intensified infection control program to reduce MRSA transmissions in a German tertiary care hospital.
      • Bahna P.
      • Dvorak T.
      • Hanna H.
      • Yasko A.W.
      • Hachem R.
      • Raad I.
      Orthopaedic metal devices coated with a novel antiseptic dye for the prevention of bacterial infections.
      • Shams W.
      • Rapp R.
      Methicillin-resistant staphylococcal infections: An important consideration for orthopedic surgeons.
      • Fawley W.
      • Parnell P.
      • Hall J.
      • Wilcox M.
      Surveillance for mupirocin resistance following introduction of routine peri-operative prophylaxis with nasal mupirocin.
      Readers are encouraged to carefully review the cited references and to determine the incidence and susceptibility of HA-MRSA and CA-MRSA in their local communities in order to develop clinically relevant, evidence-based protocols for MRSA prophylaxis and treatment.
      While we agree with Michael Pollan that MRSA is “scary,” we advocate action as opposed to fear. Mindful management of MRSA may minimize morbidity and mortality. Mmmm ….

      References

        • Pollan M.
        The way we live now: Our decrepit food factories. The New York Times Magazine December 16, 2007.
        (Accessed Dec 26, 2008)
        • Wener K.
        Health Guide: MRSA infection. The New York Times Health Guide Reviewed November 9, 2005.
        (Accessed Jan 26, 2008)
        • Altman L.K.
        New bacteria strain is striking gay men. The New York Times January 15, 2008.
        (Accessed Jan 26, 2008)
        • Diep B.A.
        • Chambers H.F.
        • Graber C.J.
        Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men.
        Ann Intern Med. 2008; 148 (online) (Accessed Jan 26, 2008)
        • Kurokouchi K.
        • Takahashi S.
        • Yamada T.
        • Yamamoto H.
        Methicillin-resistant Staphylococcus aureus–induced septic arthritis after anterior cruciate ligament reconstruction.
        Arthroscopy. 2008; 24: 615-617
        • Marcotte A.
        • Trzeciak M.
        Community-acquired methicillin-resistant Staphylococcus aureus: An emerging pathogen in orthopaedics.
        J Am Assoc Orthop Surg. 2008; 16: 98-106
        • Hassan K.
        • Koh C.
        • Karunaratne D.
        • Hughes C.
        • Giles S.
        Financial implications of plans to combat methicillin-resistant Staphylococcus aureus (MRSA) in an orthopaedic department.
        Ann R Coll Surg Engl. 2007; 89: 668-671
        • Trautmann M.
        • Pollitt A.
        • Loh U.
        • et al.
        Implementation of an intensified infection control program to reduce MRSA transmissions in a German tertiary care hospital.
        Am J Infect Control. 2007; 35: 643-649
        • Bahna P.
        • Dvorak T.
        • Hanna H.
        • Yasko A.W.
        • Hachem R.
        • Raad I.
        Orthopaedic metal devices coated with a novel antiseptic dye for the prevention of bacterial infections.
        Int J Antimicrob Agents. 2007; 29: 593-596
        • Shams W.
        • Rapp R.
        Methicillin-resistant staphylococcal infections: An important consideration for orthopedic surgeons.
        Orthopedics. 2004; 27: 565-568
        • Fawley W.
        • Parnell P.
        • Hall J.
        • Wilcox M.
        Surveillance for mupirocin resistance following introduction of routine peri-operative prophylaxis with nasal mupirocin.
        J Hosp Infect. 2006; 62: 327-332