2.5 ANCC Contact Hours The Epidemiology of Methicillin-Resistant Staphylococcus aureus in Orthopaedics Mary Atkinson Smith In the specialty of orthopaedics, methicillin-resistant Staphy- joint of a knee ( Ogston, 1984 ). In 1884, a German physi- lococcus aureus (MRSA) is a major contributor to infections cian and microbiologist named Friedrich Julius of the soft tissues, surgical sites, and joints, in addition to Rosenbach appended Staphylococcus to S. aureus increasing disability, mortality, and healthcare costs. Inap- ( Todar, 2008 ). S. aureus is an anaerobic gram-positive propriate prescribing and misuse of antibiotics have led to coccal bacterium that colonizes in the nasal passages bacterial resistance and the rapid emergence of MRSA. It is and is routinely found on the skin as normal fl ora, in the oral cavity and gastrointestinal tract ( Todar, 2008 ). It is imperative for healthcare providers and facilities to improve estimated that up to 20% of individuals are long-term quality, promote safety, and decrease costs related to MRSA carriers of S. aureus, which is the most common class infections. The healthcare profession and society as a whole of Staphylococcus that leads to Staphylococcus infec- play an important role in minimizing the transmission of tions (Kluytmans, van Belkum, & Verbrugh, 1997). S. pathogens, reducing the incidence of MRSA infections, and aureus can cause a wide range of illnesses from minor decreasing the development of future antibiotic resistant skin infections to life-threatening conditions such as pathogens. This article discusses the epidemiology of MRSA pneumonia and sepsis. It is also a common cause of and describes evidence-based guidelines pertaining to the hospital-acquired infections (HAIs) and surgical site in- prevention, minimization, and treatment of MRSA-related fections (SSIs). infections. Specifi c application to orthopaedics are discussed Penicillin is the antibiotic of choice to treat infec- in the context of patient risk factors, perioperative and post- tions caused by S. aureus . When penicillin was fi rst in- troduced in 1943, antibiotic resistance to S. aureus was operative prophylaxis, and current trends regarding educa- uncommon. Forty percent of HAIs were S. aureus re- tion and reporting strategies. sistant by 1950 with 80% being resistant by 1960 ( Chambers, 2001 ). Penicillin resistance has become ex- taphylococcus aureus bacteria are commonly tremely common, which has led to the use of penicilli- found on the skin and in the nares of healthy nase-resistant β -lactam antibiotics as fi rst-line therapy individuals and is also one of the most common to treat infections caused by S. aureus. The increased pathogenic bacteria associated with infections use of β -lactam antibiotics has now led to the emer- S of the skin and soft tissue. The misuse of antibiotics has gence of MRSA. The increased incidence of MRSA can led to bacterial resistance, and the rapid emergence of be contributed to the overuse and inappropriate pre- methicillin-resistant S. aureus (MRSA). The emergence scribing of β -lactam class of antibiotics, which includes of MRSA has created signifi cant healthcare challenges penicillin derivative antibiotics and cephalosporins. in community and hospital settings. In the specialty of Methicillin-resistant S. aureus bacteria are commonly orthopaedics, MRSA is a major contributor to surgical resistant to multiple antibiotics. This antibiotic resist- site infections, disability, increasing mortality, and ris- ance makes MRSA infections more challenging to treat ing healthcare costs. To improve the quality of care and with standard antibiotics and potentially more life decrease healthcare spending, it is important for health- threatening. Methicillin-resistant S. aureus has become care providers to be aware of the potential for the devel- problematic for hospitals and facilities that have com- opment of MRSA infections, in addition to evidence- munity-type living environments, patients with open based practices related to the prevention, minimization, and treatment of MRSA infections. The purpose of this article was to describe the development, presentation, Mary Atkinson Smith, DNP, NP-C, ONP-C , Board Certifi ed Nurse prevention, and treatment of MRSA. Practitioner and RNFA, Starkville Orthopedic Clinic, Starkville, Mississippi; Board Certifi ed Nurse Practitioner, UMMC Center for TeleHealth, Jackson, Mississippi; and Assistant Professor & Assistant Program Director for Online Programs, South University College of Nursing and Background and Description Public Health. Staphylococcus was discovered in 1880 in the United The author and planners have disclosed no potential confl icts of interest, Kingdom by surgeon Sir Alexander Ogston from puru- fi nancial or otherwise. lence that resulted from a surgical abscess within the DOI: 10.1097/NOR.0000000000000141 128 Orthopaedic Nursing • May/June 2015 • Volume 34 • Number 3 © 2015 by National Association of Orthopaedic Nurses Copyright © 2015 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. OONJ779_LRNJ779_LR 112828 009/05/159/05/15 77:08:08 PPMM wounds or implanted devices, and immunocompro- or long-term care facility. In a healthcare setting, mised individuals. HA-MRSA is frequently attributed to devices that are used in procedures and can lead to pneumonia, surgi- cal site infections, sepsis, or even death. Common types Pathogenesis and Description of HAIs include central line-associated bloodstream Bacteria are continually present on the skin surface and infections, catheter-associated urinary tract infections, are considered part of the normal skin fl ora. Twenty per- surgical site infections, and ventilator-associated pneu- cent of the population is considered to be colonized monia ( CDC, 2014b ). According to a large sample of with S. aureus and 1% of the population is considered acute care hospitals in the United States, 722,000 HAIs to be colonized with MRSA. 3,6 The nose and skin are were reported in 2011, of which 75,000 patients died common areas for MRSA colonization. Colonization during the hospitalization, and more than half of the means that bacteria are present but it does not cause an HAIs were located outside the intensive care unit ( CDC, infection unless it is able to penetrate the skin’s surface. 2014c ). An example of an orthopaedic-related An infection can develop when the skin’s surface is dis- HA-MRSA infection would be a postoperative surgical rupted and the bacteria have an easy mode of entry in site infection. the body. The Centers for Disease Control and Prevention MRSA in Orthopaedics (CDC) has listed MRSA as one of the 18 multidrug- resistant microbes, also known as a “superbug” ( CDC, Antibiotic-resistant pathogens such as MRSA can be 2014a ). Methicillin-resistant S. aureus infections are very challenging for healthcare providers and devastat- categorized as either community acquired (CA-MRSA) ing on a patient’s musculoskeletal system. The most or healthcare acquired (HA-MRSA) with CA-MRSA common diagnoses associated with MRSA infections in being more common. A large percentage of CA-MRSA the specialty of orthopaedics include cellulitis, abscess, begins as a localized skin infection that is due to a break postoperative surgical site infection, infections result- in the skin’s surface among healthy individuals, who ing from a surgically implanted device, or osteomyelitis. have not been hospitalized or have not had a recent The most frequently conducted surgical procedures due medical procedure. The majority of HA-MRSA infec- to MRSA infections are incision and drainage of skin tions can occur as the result of a break in the skins sur- and subcutaneous infection, debridement, and bone face, because of factors such as a surgical incision or the excision. insertion of medical devices. Although CA-MRSA and HA-MRSA are defi ned differently, their mode of trans- mission is still the same: direct contact with colonized Disease Progression and skin or the surface of a shared item where MRSA is Transmission present. There are many factors that contribute to the progres- sion and transmission of MRSA within community and CA-MRSA healthcare-related settings with contaminated hands, According to the CDC (2005) , there are several factors poor hygiene, and unsanitary environments being the that determine the classifi cation of CA-MRSA. A person most common. Other contributory factors include anti- must be diagnosed in an outpatient setting or have a biotic resistance and various host factors. These con- positive culture within 48 hours of a hospital admission. tributory factors address many aspects such appropri- The individual must not have a permanently implanted ate prescribing of antibiotics among providers, misuse medical device or an indwelling catheter, in addition to of antibiotics by patients, evidence-based hand hygiene a negative medical history for MRSA. Also, to be consid- practices among clinicians, and sanitary hygiene ac- ered CA-MRSA, there must not be a recent hospitaliza- tions among the general public, in addition to environ- tion or stay in a long-term care facility. mental and host-related infl uences. Other points that It is not uncommon for individuals to be colonized may be applicable to MRSA progression and transmis- with CA-MRSA and remain symptomatic. Approximately sion are also discussed in prevention and prophylaxis 80% of CA-MRSA cases present as uncomplicated skin section of this article. Table 1 provides an overview of