Staph Aureus question

Sharon · Jul 12, 2005

I did have a case like this and it did prove to be only a fracture. The scans supported this. There was no acute or six month uptake to support a systemic infection of any type. We where concerned about an infection seating at the stress fracture site because of the high risk position he was in. The individual was a post transplant recipient who was an industrial hygienist who had multiple sewage exposures. I can't remember why but there was another non-infectious cause found for the elevated WBC and shift.

BTW don't forget any swelling ("only swollen") is considered a deformity. It is not uncommon for minor fractures, i.e. stress, not to swell for days, weeks or months; sometimes not until further damage occurs like from immobility. Rarely do stress fractures show up on flat X-rays during the first six months. Actually today I just saw a facial one show up via the third CT scan that we have been looking for for 24 months. We strongly suspected it was there based on deformity (swelling) on the opposite side of the face, discomfort, warmth, temperature, and elevated WBC's. At one point a severe sinus infection occurred and was aggressively treated to prevented osteomylitis at the fracture site. I am glad my patient did not file a complaint between onset of care and the past 24 months!

bloodmonster · Jul 12, 2005

Wouldn't I have decreased ROM? My arm works perfectly fine. All I have remaining is a little bit of swelling and tenderness around my bursa sack. I can push down on the tissue around that area and come up with a +1 on the pitting edema scale. The Infection doctor had told me that I did not have a fracture and I believed him. I dont see how I would have gotten a fx in a step aerobic class. I normally work out 3 to 4 days a week without a problem. I've been a competitive swimmer all my life. I've never broken anything before.

Sharon · Jul 12, 2005

I see people all the time who continue to work through the pain, ADLs including sports. Decreased ROM is one possible sign of a fracture. Even when I did disaster rescue decreased ROM was rarely a sign of severe fractures even in the field.

Step classes are notorious for fractures check with sports medicine. Regardless you do not have confirmation of either illness. I think it was reasonable to be treated for the most likely conditions, an infection and a fracture. BTW I have never seen symptoms such as yours caused by Staph not grow Staph on culture. But then the physicians I have worked with would have cultured your arm either by swab, punch biopsy or some other form of biopsy.

Just out of curiosity - Is MRSA so rampant on your unit/facility that the ED physician automatically assumed you have it? If he was concerned that it was MRSA why did he not get an ID consult in the ED? If you are going to be concerned about how your case was handled I would be more concerned about how the initial assessment of what infection was going on and what drugs you where treated with. I have recently seen virus joint and soft tissue infections that sound just like what you have. Guess what? You haven't been covered for that.

BTW you are in the right gender and since the two labs you mention are dead on for an acute flare of collagen vascular disease, do you have any other risk factors?

bloodmonster · Jul 12, 2005

While in the ER the ER doc spoke with the I.D. Doc about my labs and symptoms. After he finished the phone conversation the ER doc told me MRSA was suggested.

As far as I know I dont have any other medical problems or history's. I've been healthy all my life. I'd hate to think that everytime I go to the gym and work out I'm going to break something. I'm not that old.

I'm still working on prooving the PCP wrong. I'm going to get an appt for an MRI on my arm. I have an appt to see someone in about 1 hour about this.

bloodmonster · Jul 12, 2005

Oh I nearly forgot your other question. Yes, I do work with a lot of patients who have MRSA. In fact, 95% of my patients either have MRSA or VRE and some have TB.

bloodmonster · Jul 13, 2005

I just came back from my Doc appt. He looked everything over from my arm to the hospital records. His conclusion was that I did not have a fx and that I contracted a bacteria which caused me to have a skin infection. Twas not Staph Aureus, just a common bacteria which caused me to have cellulitus. Cellulitis is the actual dx given to me at the hospital.

Now my next dilemma is who gets the bill for this? Does my health insurance pay for my hospital stay or should I continue to pursue workman's comp? What would you do?

ICRN2008, BSN, RN · Jul 14, 2005

Regarding your questions about your lab results, I might be able to help. I'm a medical technologist who is now studying nursing. Your elevated white count with left shift obvously suggests that you have a bacterial infection of some sort. However, negative blood cultures does NOT rule out MRSA. It only means that you have a local infection and it has not progressed to septicemia. The only way to test for MRSA is to do a susceptibility on the culture of your elbow wound. That being said, I imagine that the ER doctor is playing it safe. Considering that most of the patients you work for have MRSA and VRE, it is safe to assume that you are at risk and putting you on vanco as a precaution is prudent.

As a side note, what hospital do you work for? If the rate of resistent nosocomial infections is that high, that means that their infection control practices need to be carefully examined. Is there a screening policy in place whereby every new patient is given a nose swab? I also suggest that you get your nose swabed periodically to make sure that you are not a MRSA carrier. It's possible that you infected yourself by touching your elbow after blowing your nose (if you didn't wash your hands). I should know- I worked with S. aureus for a year, and some strains turned out to be MRSA.

bloodmonster · Jul 14, 2005

I always wash my hands. I'm a fanatical hand washer. I work at several facilities, not just one. I'm an acutes hemodialysis nurse. Most of my patients have MRSA or VRE simply because they are immuno compromised and have taken a lot of ATBS. They are in the hospital for other reasons, not just for dialysis treatments. Some come in for respiratory failure, pneumonia, broken bones, sepsis, neglect, diabetes and some are in a comlete coma. My patients are the sickest patients in the hospital because they are renal failure patient. The % of patients that I was referring to are only the patients with renal failure.

stevierae · Jul 18, 2005

Wouldn't I have decreased ROM? My arm works perfectly fine. All I have remaining is a little bit of swelling and tenderness around my bursa sack. I can push down on the tissue around that area and come up with a +1 on the pitting edema scale. The Infection doctor had told me that I did not have a fracture and I believed him. I dont see how I would have gotten a fx in a step aerobic class. I normally work out 3 to 4 days a week without a problem. I've been a competitive swimmer all my life. I've never broken anything before.

I am not sure where he got "fracture" but I do know that COMMUNITY acquired MRSA is a huge problem---don't know if it's considered an epidemic yet, but I know my OWN gym has posters everywhere---and I have seen more than my share in the operating room of young, muscular men and women who got infected with MRSA transmitted through broken skin on their elbows or upper arms while doing arm curls.

Think about it: you see people sweat all over the leather or vinyl pad on which you rest your elbows and upper arms--even if you lay a towel down, it's still sweaty, and your own towel may be sweaty or wet.

My gym now has Lysol spray disinfectant to decontam these surfaces, near each piece of Nautilus equipment. I always decontam, AND lay down a very thick, dry towel, AND take a long, hot soapy shower before leaving the gym. Can't be too careful.

That said, I just read back where your cultures did not read out S.aureus or even MRSA. Cellulitis can happen with any skin break----cat scratch, rose bush thorn, splinter---anything.

bloodmonster · Jul 19, 2005

I understand your point about picking up MRSA at the gym. I go to a private women's gym. If and when I use the equipment I always put a towel down so my skin does not touch the surface of the equipment. I havent used the equipment in over a month.. So, I seriously dont think I contracted the bacteria from the gym. The last time I was at the gym was only for a step Aerobic class and I didn't touch anything. I didn't even use the step, because I am too clumsy and afraid of tripping over it.

I am not sure where he got "fracture" but I do know that COMMUNITY acquired MRSA is a huge problem---don't know if it's considered an epidemic yet, but I know my OWN gym has posters everywhere---and I have seen more than my share in the operating room of young, muscular men and women who got infected with MRSA transmitted through broken skin on their elbows or upper arms while doing arm curls.
Think about it: you see people sweat all over the leather or vinyl pad on which you rest your elbows and upper arms--even if you lay a towel down, it's still sweaty, and your own towel may be sweaty or wet.
My gym now has Lysol spray disinfectant to decontam these surfaces, near each piece of Nautilus equipment. I always decontam, AND lay down a very thick, dry towel, AND take a long, hot soapy shower before leaving the gym. Can't be too careful.
That said, I just read back where your cultures did not read out S.aureus or even MRSA. Cellulitis can happen with any skin break----cat scratch, rose bush thorn, splinter---anything.