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Mrsa contact precautions?


So this has been bugging me for a while. The standard at my hospital is to nasal swab all newly admitted pt for mrsa. People with mrsa are placed on contact precautions. If mrsa is a contact precaution worthy disease, why do we keep finding it in the nares which is part of the respiritory tract. That would suggest airborne to me. Unless all the mrsa pt are picking there nose. Lol

Nares are a good place to colonize bugs of all kinds, including skin infections. This is for multiple reasons, but one of which (and most important) is people touch their noses a ridiculously large amount of times in a given day. It's something that you don't notice you do, but the one report I saw said 5 - 10 times in a normal given hour. It's a nervous tick for many, also. Also, being nice and moist in this particular area breeds bacteria like its the nares JOBS.

The purpose of a PCR nasal swab isn't to say, "This person has skin-type MRSA latent infection", it's purpose is to say, "This person has MRSA. Period."

The positive of this finding is that if you're going for OHS or other chest or above the diaphragm surgeries, you can treat the nares with bacroban to hopefully rid the person of infection. Alternatively, you know who to keep behind the proverbial bars and who is good to go.

The funny thing is, and we definitely haven't started doing this, but a major hospital in our state (I don't want to get any friends or myself in trouble) no longer routinely isolates patients of this type, and instead are OK with putting these patients in the same room as non-infected people.

Remember: EVERYBODY has staph-aureus on their skin - EVERYBODY. Some people have a mildly mutated variant that is sometimes only resistant to ONE antibiotic, others have MRSA that is resistant to nearly EVERYTHING. I once took care of a patient that the C&S came back as being resistant or intermediately resistant to nearly every antibiotic group except 2. The one group the patient had an anaphylaxis reaction to, so the docs treatment for the LATENT infection (that could very easily become active in this patients case) was a regimen of 6 months of ATB.

Consequently that's the only time I have been afraid of MRSA. ... had this person in the end been allergic to the only ATB left and developed an active infection, she would have been in a world of hurt.

Scarlette Wings

Specializes in M/S, ICU, ICP. Has 27 years experience.

the prior poster gave an excellent reply. at my hospital we do not swab all patients but we do have a high risk group that meet criteria for screening. you are correct that if the organisms are in the nose then they are in the respiratory track. patients that are screened mrsa positive for colonization will almost always have it in their sputum if they have pneumonia or a respiratory infection.

however the precautions used with mrsa then changes from only contact precautions to droplet precautions as well. droplet precautions require the surgical masks and the 3-6 foot distance because the organisms are spread on droplets.

the doctors do elect to treat the pre-op surgery patients that are planning to have any cardiac or orthopedic surgeries in order to decrease the potential for surgical site infections. all of our high risk patients that have positive nare screens are placed in contact isolation. the rational for the isolation is that it helps decrease the potential for spreading mrsa from colonized patients to other patients that may be non-colonized. hope this helps.

Evidence-based data does not support what a previous poster suggested --that we are ALL colonized with staph aureus. In fact, numbers are markedly lower: 32.4 percent for staph aureus and 0.8 percent for MRSA.

I've yet to see evidence-based data saying that all of us or even a majority are staph aureus carriers.

See: http://www.ncbi.nlm.nih.gov/pubmed/16362880

For 2001-2002, national S. aureus and MRSA colonization prevalence estimates were 32.4% (95% confidence interval [CI], 30.7%-34.1%) and 0.8% (95% CI, 0.4%-1.4%), respectively, and population estimates were 89.4 million persons (95% CI, 84.8-94.1 million persons) and 2.3 million persons (95% CI, 1.2-3.8 million persons), respectively.

General E. Speaking, RN, RN

Specializes in floor to ICU.

The Infectious Disease doctor at work told me to never let anyone swab your nares....lol.

here's some more information...this is an interesting subject...:

colonization rates for mrsa (rising) and s. aureus (declining)

the prevalence of colonization with s. aureus decreased from 32.4% in 2001-2002 to 28.6% in 2003-2004 (p or =60 years, diabetes, and poverty in females. in 2003-2004, a total of 19.7% (95% confidence interval, 12.4%-28.8%) of mrsa-colonized persons carried a pfge type associated with community transmission.

conclusions: nasal colonization with mrsa has increased in the united states, despite an overall decrease in nasal colonization with s. aureus.

source: http://www.ncbi.nlm.nih.gov/pubmed/18422434

methicillin sensitive staph aureus among orthopedic surgeons

here's a disturbing study that found higher rates of methicillin sensitive staph aureus among orthopedic surgeons at a particular hospital compared to a high-risk patient group (mrsa rates were similar):

results a total of 135 physicians were screened. of those physicians, 1.5% were positive for methicillin-resistant staphylococcus aureus and 35.7% were positive for methicillin-sensitive staphylococcus aureus. none of the sixty-one residents were positive for methicillin-resistant staphylococcus aureus. however, 59% were positive for methicillin-sensitive staphylococcus aureus. of the seventy-four attending surgeons, 2.7% were positive for methicillin-resistant staphylococcus aureus and 23.3%, for methicillin-sensitive staphylococcus aureus. previous studies at our institution have demonstrated a 2.17% prevalence of nasal carriage of methicillin-resistant staphylococcus aureus and an 18% rate of methicillin-sensitive staphylococcus aureus in high-risk patients. thus, no difference was found between the prevalence of methicillin-resistant staphylococcus aureus in residents or attending surgeons and that in the high-risk patients. however, the prevalence of methicillin-sensitive staphylococcus aureus colonization in the surgeons (35.7%) was significantly higher than that in the high-risk patient group (18%) (p

source: http://www.ejbjs.org/cgi/content/abstract/92/9/1815

s. aureus epidemiology

excerpt: humans are a natural reservoir for s. aureus, and asymptomatic colonization is far more common than infection. colonization of the nasopharynx, perineum, or skin, particularly if the cutaneous barrier has been disrupted or damaged, may occur shortly after birth and may recur anytime thereafter (6). family members of a colonized infant may also become colonized. transmission occurs by direct contact to a colonized carrier. carriage rates are 25% to 50%; higher rates than in the general population are observed in injection drug users, persons with insulin-dependent diabetes, patients with dermatologic conditions, patients with long-term indwelling intravascular catheters, and health-care workers (7). young children tend to have higher colonization rates, probably because of their frequent contact with respiratory secretions (8,9). colonization may be transient or persistent and can last for years (10).

source: http://www.cdc.gov/ncidod/eid/vol7no2/chambers.htm

nasal colonization may not be accurate marker for predicting risk for mrsa infections

discordance between staphylococcus aureus isolates cultured from nasal and wound sites and discrepancies between nasal colonization status and incidence of recurrent infections among children suggests that nasal colonization may not be an accurate marker for predicting which children are at risk for recurrent community-associated methicillin-resistant staphylococcus aureus skin infections.

"a striking 33% of our patients either grew mrsa from their wound but methicillin-susceptible s. aureus from their nose or mssa from their wound but mrsa from their nose," the researchers wrote.

furthermore, patients with mrsa isolates obtained from nasal culture after initial skin infection had a 19% recurrence risk compared with the 42% recurrence risk observed in patients without mrsa-positive nasal cultures.

...patients are getting recurrences of mrsa infections from sources other than the nose, which we knew anyway because risk factors include close body contact with people that are infected, contaminated fomites or sports equipment. we should use caution in our interpretation until there are more data.

source: http://www.infectiousdiseasenews.com/article/38944.aspx

Here's something the OP might find of special interest:

MERCK: Staphylococcus aureus is present in the nose of adults (temporarily in 60% and permanently in 20 to 30%) and sometimes on the skin. People who have the bacteria but do not have any symptoms caused by the bacteria are called carriers. People most likely to be carriers include those whose skin is repeatedly punctured or broken, such as the following:

  • People who have diabetes mellitus and have to regularly inject insulin.
  • People who inject illegal drugs
  • People who are being treated with hemodialysis or chronic ambulatory peritoneal dialysis
  • People with skin infections, AIDS, or previous staphylococcal bloodstream infections

People can move the bacteria from their nose by to other body parts with their hands, sometimes leading to infection. Carriers can develop infection if they have surgery, are treated with hemodialysis or chronic ambulatory peritoneal dialysis, or have AIDS.

The bacteria can spread from person to person by direct contact, through contaminated objects (such as telephones, door knobs, television remote controls, or elevator buttons), or, less often, by inhalation of infected droplets dispersed by sneezing or coughing.

Source: http://www.merckmanuals.com/home/sec17/ch190/ch190t.html

That's the highest colonization rate I've seen for S. aureus --60 percent...would love to see the study data that supports that figure...