1 THE ROLE OF ADVANCED PRACTICE NURSING IN COMMUNITY-ACQUIRED MRSA INFECTION: IMPLICATION FOR PRACTICE AND COMMUNITY HEALTH by James G. Baxter A Master’s Project Submitted to the Faculty of the COLLEGE OF NURSING In Partial Fulfillment of the Requirements For the Degree of MASTER OF SCIENCE In the Graduate College THE UNIVERSITY OF ARIZONA 2006 2 STATEMENT BY AUTHOR This project has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library. Brief quotations from this project are allowable without special permission, provided that accurate acknowledgement or source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the head of the major department or the Dean of the Graduate College when in his or her judgment the proposed use of the material is in the interest of scholarship.
In all other instances, however, permission must be obtained from the author. SIGNED: ________________________________________ 3 TABLE OF CONTENTS LIST OF ILLUSTRATIONS……………………………………………………………5 LIST OF TABLES………………………………………………………………………6 ABSTRACT…………………………………………………………………………….7 1 CHAPTER 1 PURPOSE AND SIGNIFICANCE Introduction……………………………………………………………………….8 Purpose of Project………………………………………………………………….9 Background and Significance……………………………………………………….14 2 CHAPTER 2 THEORETICAL FRAMEWORK LITERATURE REVIEW Introduction……………………………………………………………………….15 Review of Literature……………………………………………………………….33 Areas for Future Research………………………………………………….41 3 CHAPTER 3 IMPLICATION FOR PRACTICE AND COMMUNITY HEALTH Introduction……………………………………………………………………….43 Implications for Advanced Practice Nursing.44 Diagnosis and Treatment Algorithm…………………………………………45 Outpatient Antibiotic Therapy………………………………………………45 Outpatient Parenteral Antibiotic Therapy…………………………………….47 Implications for Community Health………………………………………….48 Summary…………………………………………………………………………51 4 CHAPTER 4 EVALUATION Introduction………………………………………………………………………53 Plans for Evaluation………………………………………………………………53 Strengths of Project……………………………………………………………….54 Limitations of Project…………………………………………………………….55 4 TABLE OF CONTENTS – Continued APPENDIX A………………………………………………………………………….59 CA-MRSA ALGORITHM…………………………………………………………….60 CA-MRSA ALGORITHM SUPPLEMENT……………………………………………61 CA-MRSA FOCUSED HISTORY TOOL…………………………………………….69 5 LIST OF ILLUSTRATIONS FIGURE 1: Evolution of MRSA.56 FIGURE 2: CA-MRSA Algorithm…………………………………………………….60 6 LIST OF TABLES TABLE 1…………………………………………………………………………….58 7 ABSTRACT In the last 10-15 years community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has become increasingly recognized as a significant, worldwide health problem. CA-MRSA causes skin and soft tissue infections as well as more serious, sometimes life-threatening, pneumonias in otherwise healthy people. Outbreaks of CA- MRSA infections have occurred in unexpected groups.
Some CA-MRSA strains are particularly virulent and have achieved ecological stability, raising concern that those strains of CA-MRSA could become endemic in certain areas of the country and within certain populations. No generally accepted diagnostic, treatment, or prevention guidelines for practitioners currently exist for CA-MRSA as there are for hospital-acquired MRSA infections (HA-MRSA). This paper reviews currently available pathophysiological, epidemiological, and historical information from various journals and texts, as well as current diagnostic and treatment approaches. The treatment guidelines and algorithm presented here are designed to aid practitioners in their clinical decision-making and interventions when addressing potential CA-MRSA infections.
8 CHAPTER 1 PURPOSE AND SIGNIFICANCE Introduction The advent of antibiotics brought a new era in the treatment of infectious diseases and in the ability of health care providers to care for their patients. Antibiotics are a double- edged sword because the organisms we treat can mutate and develop resistance to the various actions of the antibiotics. Staphylococcus aureus (SA) has been recognized as a challenging organism in human infections since the development of germ theory and never more so than now, in the 21st century, because of SA’s ability to develop resistance to the currently available antimicrobial arsenal. Currently Methicillin Resistant Staphylococcus Aureus (MRSA) infections present such a major health care concern (Chini, Petinake, Foka, Paratiras, Dimitracopoulos, & Spiliopolou, 2006; Crisostomo, Westh, Tomasz, Chung, Oliviera, & deLencastre, 2001; Hulten et al., 2006; Ribeiro et al., 2005; Vandenesch et al., 2003), that they may constitute a worldwide health care crisis.
MRSA has become endemic in many health care institutions (approximately 50% prevalence in the U. and approximately 20% in Europe) and new MRSA strains are developing in the broader community that are affecting people without recognized risk factors for nosocomial MRSA infection (Appelbaum, 2006; Carelton, Diep, Charlebois, Sensabaugh, & Perdreau- Remington, 2004; Henderson, 2006; Naimi et al., 2003; Salgado, Farr, & Calfee, 2003). Problem Statement Staphylococcus aureus (SA) has been a leading cause of infection in humans since bacteria were identified as a cause of illness and death. With the advent of antibiotics morbidity and mortality from SA has drastically decreased; however, SA has shown a remarkable ability to develop resistance to the antibiotics used against it.
This ability to 9 develop resistance to anti-microbial agents has led, since the early 1990’s, to a worldwide epidemic of drug resistant SA. Methicillin, introduced into clinical use in 1960 to replace penicillin (PCN), which had become ineffective in treating SA infections, rapidly fell prey to SA’s ability to develop drug resistance: Within a year of methicillin’s introduction resistant strains of SA had already been identified, with additional resistance rapidly developing to streptomycin, tetracycline and in some cases erythromycin (Livermore, 2000; Schito, 2006; Oliveira, Tomasz, & deLencastre, 2002; Rice, 2006). In 2006 Methicillin resistant SA (MRSA) is a worldwide problem involving multi-drug resistant infections, increasing levels of morbidity and mortality, and costing millions of healthcare dollars every year. Since the 1990's MRSA infections have moved out of the health care inpatient setting into previously unaffected populations in the community.
The combination of SA's ability to rapidly develop resistance to antibiotics and its spread into the larger, healthy community makes MRSA infections a concern for patients, practitioners, public and community health workers, and governmental leaders. Purpose of project No current guidelines exist for primary care and family practitioners for the diagnosis and treatment of community-acquired methicillin-resistant (CA-MRSA) infections in the community. A review of Cochrane, DARE and the ACP Book Club databases for the years 2000 through 2006 revealed no current published guidelines available for practitioners. Many recent articles have reviewed pathophysiology, epidemiology, diagnosis and treatment in specific populations or with specific types of infections.
However, no general guidelines are currently available for practitioners to use in general practice to diagnosis and treat the variety of CA-MRSA infections presented to them. Additionally, information about CA- 10 MRSA infections is not readily available to primary care and family practitioners in forms they can access or readily use. This paper will present both diagnosis and treatment guidelines and decision-making algorithms derived from currently available scientific literature. Background and Significance Staphylococcus aureus has been a constant in human history, associated with infections of the skin, wounds, respiratory system, central nervous system, urinary tract, and blood stream (Enright, Robinson, Randle, Feil, Grundman, & Spratt, 2006; Oliveira et al., 2002; Sabol, Eshevarria, & Lewis, 2006 ).
aureus has the ability to colonize humans without causing symptoms until the immune system is unable to control bacterial growth. aureus’s “versatility of pathogenic strategies, number of virulence factors, and capacity to survive and multiply in a wide range of environments…is unsurpassed by any other human pathogen” (Oliveira, p. aureus has multiple mechanisms to rapidly develop resistance to drugs: use of plasmid borne penicillinase to degrade the antibiotic before it can reach its target; alteration in cell wall antibiotic binding sites that prevent drug binding; protein A and proteases that alter IgG antibody function and effectiveness; and superantigens that bind to major histocompatibility factors and moderate host immune function (Projan & Novick, 1997, pp. MRSA infections were initially a hospital based problem associated with defined risk factors: compromised immune system, indwelling invasive devices, serious chronic illness, extended hospitalization (especially in intensive care units), use of multiple broad spectrum antibiotics, and surgical procedures (Lewis, Salyers, Taber, & Was, 2002; Vandenesch et al.
These hospital-associated MRSA (HA-MRSA) infections were associated with a small 11 number of S. aureus clones strains, with defined genetic identifiers, and were frequently multi-drug resistant (Oliveira et al., 2002; Ribeiro et al. Methicillin resistance in S. aureus is mediated primarily by chromosomal coding (mec DNA) for an altered penicillin- binding protein (PBP2a) with lowered binding affinity for beta-lactam antibiotics (Lewis, p.
HA-MRSA is now considered endemic in many hospitals worldwide and has spread to long-term and extended care facilities (Fridkin et al. In more recent years, MRSA infections have been isolated in patients without previously identified risk factors for HA-MRSA; the MRSA strains for these CA-MRSA infections are distinct from and unrelated to HA-MRSA strains (Chen, Huang, Chiu, Su, & Lin, 2005; Fridkin; Ribeiro). CA-MRSA strains have spread worldwide and been responsible for outbreaks of mild to moderate skin and soft tissue infections as well as fatal respiratory infections in healthy adults and children (Charlebois et al., 2003; Cohen, 2005; Francis et al., 2005; Frazee, Salz, Lambert, & Perdreau-Remington, 2005; Fridkin; Hageman et al., 2006; Hulten et al. Outbreaks of CA-MRSA infections have occurred in athletic teams, prison populations, military recruits, medically underserved urban poor, and in relatively isolated native American populations (Cohen; Ellis, Hospenthal, Dooley, Gray, & Murray, 2004; Fridkin; Gilbert et al., 2006; MMWR; MMWR, 2003; Stemper, Shulka, & Reed., 2004; Young et al., 2004) causing significant costs to individuals as well as the communities: direct health care costs, lost work or school time, altered quality of life, and increased institutional manpower and resource costs (Muto et al.,2003; Pittet et al.
Definitions The following definitions are used in this paper: 1. Community-acquired (associated) methicillin-resistant s. aureus (Carleton et al., 12 2004; Gorwitz et al., 2006; Kowalski, Berbari, & Osmon, 2005; Moran et al., 2006; Salgado et al. aureus strains isolated from hospitalized patients <24 hours after admission that are resistant to methicillin (oxacillin) and have limited resistance to other antibiotic classes -S.
aureus strains carrying the SCCmec IV(a) gene, and (frequently) associated with additional virulence factors such as Panton-Valentine leukocidin -MRSA strains that have limited resistance to antibiotics other than beta-lactam agents and isolated outside the hospital -MRSA strains with above characteristics in patients that have no identified risk factors for HA-MRSA infections 2. Hospital-acquired methicillin-resistant S. aureus (Charlebois et al., 2002; Hulten et al., 2006; Naimi et al., 2003) -MRSA isolates collected from hospitalized patients >24-48 hours after admission that are multi-drug resistant -MRSA strains carrying SCCmecI-III genes -MRSA strains with above characteristics that are associated with identified risk factors (for example, recent hospitalization, frequent/multiple antibiotic use, serious chronic illness, indwelling invasive devices) 3. Beta-lactam antibiotics: class of antibiotics with a fused beta-lactam ring structure that inhibits bacterial growth by altering synthesis of the cell wall.
13 These antibiotics include natural and semisynthetic penicillins, extended spectrum penicillins, cephalosporins, imipenem, and aztrenonam. 180; Spencer, Nichols, Lipkin, Sabo, & West, 1986). Tetracyclines: broad spectrum antibiotics with a four fused benzene structure that are bacteriostatic; divided into 3 groups: short-acting, intermediate- acting, and long-acting compounds. Examples are tetracycline, doxycycline, minocycline (Williams, 2004, pp.
Macrolides and clindamycin: different chemical structures but having similar antimicrobial activity, mechanism of resistance, and action on bacteria. They inhibit protein synthesis in bacteria and are bacteriostatic. Examples are erythromycin, clarithromycin, azithromycin (Forrest & Oldach, 2004, p. Glycopeptides: vancomycin and teicoplanin.
Bacteriocidal antibiotics that inhibit bacterial cell wall synthesis; effective against gram-positive organisms (Davaro & Glew, 2004, pp. Aminoglycosides: antibiotics containing two or more amino sugars in glycoside linkage with a hexose nucleus, that are bacteriocidal (Spencer, 1986, p. 216) Examples are gentamicin, streptomycin, kanamycin, and neomycin. Quinolones: a group of structurally similar antibiotics that act by inhibiting bacterial DNA synthesis (bacteriocidal).
Examples are ciprofloxacin, moxifloxacin, ofloxacin, and levofloxacin (Andriole, 2004, pp. Multilocus-sequencing type (MLST): sequencing-based technique that is based on the DNA sequencing on the internal fragments of seven unlinked housekeeping genes (Oliveira et al. Pulsed-field gel electrophoresis (PFGE): molecular typing technique using macrorestriction pattern of chromosomal DNA after Smal digestion and separation of the fragments. Smal—bacterial genetic structure used in molecular typing (Oliveira, 2002) Summary S.
aureus infections have progressed from the hospital environment where they developed methicillin resistance and moved into the community with this antibiotic resistance. CA-MRSA is becoming as significant a health care problem as HA-MRSA. However, no guidelines for diagnosis, treatment, and prevention of transmission of CA- MRSA have been developed to date, leaving primary care practitioners searching about for the safest, most effective, and most cost effective clinical interventions.