Paying Through the Nose? MRSA Treatment and Strategies for Healthcare Workers
The scope of the nation’s problem with methicillin-resistant Staphylococcus aureus (MRSA) hit me a few years back when I was chatting with a physician client who is a world expert on the bug. He had recently been called in to address an outbreak of MRSA within an NFL team, and as we spoke, enormous drums of antiseptic were being sprayed onto the artificial turf of a Big 10 stadium in an attempt to eradicate a recalcitrant college team epidemic. A big issue with the pro team was shared towels, my client informed me, but although that could be remedied, there were still other transmission vectors and sources that couldn’t even be identified, much less squelched. MRSA is still a challenge in both elite and recreational athletics, and it doesn’t look like it’s going anywhere soon.
As MRSA is everywhere and needs simply an open pore or microscopic skin abrasion to enter the body, it gets tossed back and forth like a ball in a pick-up game. We spread community-acquired (CA) MRSA to the OR and the wards when we go in for even minor surgery, where functionally speaking, it becomes hospital-acquired (HA) MRSA to the unlucky soul who contracts it while admitted for, say, an episode of diverticulitis.
The Role of Health Care Workers in Spreading MRSA
Exactly how MRSA is spread within the hospital environment has been the subject of much study over the last decade. Inanimate objects (fomites), such as furniture and equipment have been identified as large contributors. But attention has more recently turned to health care workers as another vector, as it has been established that roughly 5% are carriers of MRSA by virtue of being colonized (most frequently in the nares, which is also associated with hand contamination). This is in addition to the usual method of spreading disease by touching a contaminated patient then going to another bed, without proper decontamination in between.
In order to determine if a health care worker is, indeed, the source of a patient’s infection, cultures showing a match in pathogens have to be obtained. It is currently debated whether, in lieu of proof of a definitive cause-and-effect relationship, it can be assumed that all colonized health care workers are putting patients at risk. Some institutions screen all workers and require treatment for those colonized, while some only screen during outbreaks, the definition of which depends on the size of the ward and facility.
Mupirocin as a Standard of Care to Treat Colonized Providers
This is where knowledgeable pharmacists can aid health care workers and professionals. The management of health care providers colonized with MRSA is based on the standards developed for treating patients and published by groups like the Infectious Diseases Society of America in their guidelines. Studies show excellent, albeit often temporary, clearance of MSRA with the method described below.
Topical mupirocin in ointment form is the standard of care, applied intranasally with a cotton swab twice per day for 5-10 days. Mupirocin is also sometimes compounded for administration as a nasal spray in a squeeze bottle or for use in nasal irrigation devices, such as a Neti pot or bulb syringe. This can be accomplished by either preparing a liquid mupirocin solution for further dilution in sterile saline or by dissolving a water soluble formulation of the ointment in saline. A compounding pharmaceutical provider, like PNA, is the best resource for both the ointment and nasal delivery mechanisms, as the correct percentage of mupirocin in the carrying agent is vital to its efficacy.
Originally isolated from Pseudomonas fluorscens, mupirocin is bacteriostatic at low concentrations and bacteriocidal at high concentrations. It inhibits protein synthesis in Staphylococcus aureus by binding to the isoleucyl-transfer RNA synthetase.
Issues with Current MRSA Treatment and Management Strategies
There are a number of issues that have been raised with the current methods of MRSA treatment in health care workers.
- Universal screening of all workers is costly and time consuming to identify the 5% who potentially, but not definitively, pose the greatest risk to patients.
- Decolonization is a short-term solution (not to be confused with eradication). It is widely known that colonization will likely return within approximately a year in health care workers who undergo decolonization therapy.
- Research supporting and methodizing decolonization has largely been focused on reducing infections pre-procedure in colonized patients, not health care workers.
- It is unclear whether mupirocin alone should be used or mupirocin with adjunctive therapies, such as body washes with chlorhexidine, bleach, benzoyl peroxide or triclosan and systemic agents, including rifampin, tetracyclines, or TMP-sulfa.
- Mupirocin-resistant strains of MRSA have been identified. While good clearance is still observed even with mupirocin-resistant strains (likely due to extremely high MICs achieved with standard dosing), potential for greater resistance exists. Pharmacists should work together with their institutions’ infectious disease specialists and laboratory to monitor antibiogram trends that would indicate resistance patterns.
Recommendations Going Forward
While your institution may mandate adherence to certain protocols or guidelines, there are always opportunities for reassessment and improvement. Pharmacy can be a driver for these recommendations, working as a team with ID and the lab. The following are some suggestions in going forward with managing health care staff colonized or at risk of colonization with MRSA:
- Re-visit your institution’s protocols for treating asymptomatic health care workers, particularly if universal screening is used. Advocate for devoting budget and lab resources to identifying causative agents and aggressively treating those individuals.
- With staff turnover and general absentmindedness, it pays to conduct hand-washing information campaigns at regular intervals. This can assist not only with the reduction of MRSA, but also with bacteria that are not susceptible to alcohol-based hand gels, such as Clostridium difficile.
- If clinicians are recommending body washes in conjunction with mupirocin therapy, consider suggesting other under-researched but effective materials, such as tea tree oil.
- Don’t forget to look at all possible vectors for contamination. Remind staff management that after patient contact, health care workers can de-glove, de-gown, toss booties, wipe stethoscopes and wash their hands, but what remains to dangle in the field over the next patient? Often it’s the worker’s ID badge.
I remember attending a problem conference at a level one trauma and top transplant center, where it was discussed that an ICU nurse’s laminated tag had been cultured with over two dozen bacteria. These badges are handled sometimes hundreds of times per day for ward access and even cafeteria payment. If you’re a hospital pharmacist who frequents the ICU, NICU, ER, or burn unit, spend a day tracking where your badge has traveled in the course of 24 hours.
Think about suggesting that your facility ask workers to disinfect badge as with equipment between patients, replace cloth lanyards with plastic or even better, do away with lanyards and use clips or retractable devices.
Initiate an overall protocol for the judicious use of mupirocin. While other agents are in development for the treatment of MRSA, until they reach the market, conservation of existing therapies is vital. Reserve mupirocin for cases where it must be used, thereby guarding it for future treatment of MRSA and other Gram-positive infections.
By their very nature, hospitals will be incubators for pathogens, and the risk of worker colonization and infection will always be present. But with smart policies, forward-thinking practices, intelligent use of mupirocin, and a shift in culture, the likelihood of MRSA infections can be greatly reduced.
To learn more about what innovative pharmaceutical solutions and first-rate customer service can do to help keep your prescribers and patients healthy, contact PNA today.