Risk Factors for MRSA in Long-Term Care Facilities

Risk Factors for MRSA in Long-Term Care Facilities This research proposal will propose a study on the prevalence of MRSA colonization among older residents in the nursing home setting and associated risk factor for infection in the long-term care resident. The work will first briefly introduce MRSA infection, outline the general and specific vulnerabilities of patients in LTCFs and demonstrate a possible way to research this population with regard to this disease in a long-term qualitative study.

In brief the proposal is for long-term study of all patients entering a local LTCF for incidence of MRSA (done by nasal mucosal swab, visible infection site swab or positive MRSA culture on any given fluid causing infection). The work will then state and develop criteria for "colonization" of MRSA either in benign or infected form and develop a set of vulnerability criteria that raise the risk factors of certain patients in the LTC setting.

Research Proposal: Incidence & Risk Factors for MRSA in Long-Term Care Facilities" Nosocomial infections are a common occurrence in hospitalized patients and often such infections are resistant to treatment.

"70% of hospital-acquired bacterial infections in the United States -- which kill 90,000 Americans a year -- are resistant to at least one drug, according to the Centers for Disease Control and Prevention." (Wenner, 2008, p.11) Challenges to the immune system, open wounds, previous exposure to antimicrobial treatments, and open systems associated with treatment such as chest tubes and more commonly in long-term care facilities Foley urinary catheters all increase the opportunity to acquire one of the highly concentrated infectious diseases that are floating around and to be found on surfaces within institutions such as hospitals and long-term care facilities seems to rise significantly.

A particularly vulnerable human population is the elderly as they often have additional physical challenges that yet again increase the occurrences of opportunistic infections both in the community and in hospitals. Long-term care facilities are also often populated by patients who need longer periods of recovery, physical, occupational therapy, dietary therapy and assistance with activities of daily living than the few days of hospital treatment can afford them, for any given disease or surgical recovery period.

These people, often elderly then end up in long-term care facilities as their post treatment limited mobility and infirmary cannot be sustained in a home setting, either for support reasons or individual reasons of need. It is therefore fair to assume that these patients would have a greater incidence of transferring hospital acquired infectious diseases into long-term care facilities, where they are then spread to yet others.

Strausbaugh, Crossley, Nurse & Thrupp suggest that in the LTC setting person to person contact, between health care workers hands and patients is the most common means of transport for these "super bugs," whether they enter via colonized patient or mutate into antibiotic resistant strains while at the LTCF.

Strausbaugh, Crossley, Nurse & Thrupp also stress that patients at greatest risk for colonization of MRSA and other resistant bacteria are "serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy." (Strausbaugh, Crossley, Nurse & Thrupp, 1996, p.

129) Most importantly the researchers suggest that many LTCF do not have systems and procedures in place to help eliminate these bacteria and that there are even cases where they become aggressive and rapidly populate the LTCF population, including patients as well as high functioning staff. (Strausbaugh, Crossley, Nurse & Thrupp, 1996, p. 129) Staphylococcus aureus and several other infectious agents are therefore a frequent occurrence in the LTC setting and increasingly these agents are antibiotic resistant.

The danger then becomes one of logical adaptive bacterial behavior, as the diseases are treated with wide spectrum antibiotics, eradicating only weak non-adaptive strains and leaving behind those increasingly capable of adapting beyond the scope of known treatments. These strong bacteria then become capable of colonization in the body, where not unlike a cancer they work through the transport systems of the body and occur in traditional (skin eruptions) or worse attack deeper organ and bone systems, all while failing to respond to more and more antimicrobial medications.

(Hughes & Andersson, 2001, p. 16) Colonized patients then experience near constant outbreaks of the disease for the rest of their lives or are eventually killed by the bacteria as the disease attacks virulently to vital functioning areas of the body. One of the most unpredictable and destructive of these known "super bugs" is MRSA or Methicillin-resistant Staphylococcus aureus, which frequently colonizes in patients and is resistant even to the strongest of antibacterial treatment. (Hughes & Andersson, 2001, p.

1) Statement of the Problem Due to the high incidence of nosocomial infections in LTCF as well as antibiotic resistant strains of bacteria, the most troubling of which seems to be MRSA, for its unpredictability, given that it can do little harm but a topical skin infection, show no symptomology whatsoever or systematically attach vital systems of the body ending in serious illness or even mortality LTCFs are in need of specialized research.

One other issue with regard to MRSA is that community acquired or CAMRSA as well as known and historical strains of MRSA are intermingling in institutions and developing even more resistant strains of disease. (Gorak, Yamada & Brown, 1999, pp.

797-800) (Rutledge, 2007, NP) LTCF residents are also in a situation that is helpful for research, in that they are concentrated, generally spend significant periods of time in facilities, as apposed to high turnover rates in hospitals and clinics and are likely to allow limited research to improve their own situation and that of others. This vulnerable population is then demonstrative of a good research base to help better understand how MRSA (and other "super bugs") evolve in these settings and how they can be better dealt with there and elsewhere.

Despite this situation only limited research has been conducted on this population and a great deal more could and should be done to decrease the odds of infection, further disease compromises and most importantly mortality from secondary infections such as MRSA. Background and Significance of the Study Bacteria have a natural capacity to adapt to treatment, as the weak non-adaptive strains of disease are killed off by standard treatment leaving behind those that are adaptive and therefore capable of resisting all or most antibiotic treatment.

These resistant bugs then reproduce in the original host or in new hosts repeatedly as a simple means of normal functioning. When hosts deposit these adaptive bacteria on surfaces, in the air or directly to new hosts the bacteria then goes through the whole process again, and each time the new bacteria that emerges is more capable of resistance to standard treatment.

Hughes and Andersson in fact argue that if antibiotic treatment were never introduced into the system bacteria would not have needed to adapt microbiologically to survive and might never have become capable of resistance to treatment. (Hughes & Andersson, 2001, p. 16) in other words they argue that resistance is largely our own fault for repeatedly exposing rather benign bacteria to antibiotics when it might have been possible for our own immune systems to fight off the infection naturally.

The number of strains of resistant bacteria are simply doing what they are programmed to do and if we had been more restrictive of antibiotic use and less reliant on the "miracles" of modern medicine the world would not be in such a threatened state at this time. If we had simply treated only those infections that we knew to be life threatening and/or permanently damaging with antibiotics then most would likely still be effective.

"There would be no need for bacteria to accumulate mutations or acquire extrachromosomal DNA specifying resistance mechanisms if it were not for the use of antibiotics." (p. 16) Statement of the Purpose Knowledge of the prevalence of MRSA colonization is important to controlling the spread of infection. Determine the prevalence of MRSA colonization among older residents in the LTC setting and to identify resident risk factors for colonization are of high priority in the development of treatment, both prophylactic and primary.

Research Question What is the Incidence of MRSA in LTCF patients and among these patients who are at highest risk for infection and spreading of it? Review of the Literature Though there are several empirical studies on MRSA, there are only limited numbers on LTCF patients. This work will therefore review those available studies on all populations, including but not limited to LTC patients. This will offer a broader look at the problem and close with a more specific look at LTC incidence and susceptibility to MRSA.

It has been previously stated that LTC studies on MRSA are limited, even more limited are those which develop case studies on treatment and eradication of the problem in individuals and facilities. One of the most important aspects of the disease epidemiology is understanding how it has evolved through the whole of the health care system to become such a serious problem.

Looking more generally at how the spread of resistant bacteria has advanced over the last few years one study traces the historical precedence of antibiotic resistant strains of bacteria. This work offers a plethora of good information about the seriousness of the problem with MRSA as well as other less common but equally serious bacterial strains and how antibiotic over-utilization and patient non-compliance has added tot the problem. In Hughes, D. Andersson, D.I.

(2001) book length discussion, Antibiotic Development and Resistance many questions regarding the natural progression of bacterial resistance from the very beginning of antibiotic therapy is discussed. The work details ways in which individual bacterial diseases have progressed as a result of over-utilization of antibacterial (and especially broad spectrum) antibiotics, to treat non-life threatening infections and even viral infections has exacerbated the ineffective nature of antibiotics.

The work traces the history of antibiotics and the assumption by many that there will always be a newer and more specific strain of antibiotics available when a new or emerging bacteria arises in the population and is worth a significant look to develop a clearer understanding of the growth and development of the problem.

In one rather fundamental study MRSA is looked at from a community (CA) level, mapping the incidence of CAMRSA into something that then becomes nosocomial or hospital based, with different genetically mutated MRSA infectious agents mixing and becoming even more adaptive. In this empirical review Rutledge (2007) discusses how community acquired strains (those identified 48 or less prior to hospital admissions) and nosocomial infections (those identified 48 hours or longer after hospital admission) are commingling in the hospital setting to become even less clearly identified and more adaptive to resistance.

Coello, Glynn, Gasper, Picazo & Fereres (1997) stress that hospitalized patients have similar empirical risk factors for the development of colonized (non-infection causing) MRSA that then transforms to cause infection as LTC residents. In hospital outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) many patients are initially colonized without infection. The reasons why some progress to infection while others do not are not known. A cohort of 479 hospital patients, initially only colonized with MRSA, was followed prospectively for the development of MRSA infection.

Risk factors for progression to infection were assessed using Cox proportional hazards survival analysis. Fifty-three patients (11 1%) developed 68 MRSA infections. Intensive care setting, administration of three or more antibiotics, ulcers, surgical wounds, nasogastric or endotracheal tubes, drains, and urinary or intravenous catheterization were all associated with increased rates of MRSA infection. Risk factors for conversion to MRSA infections then become greater as condition deteriorates, and as patients undergo invasive long-term treatments.

It is for this reason that screening might need to be universal as colonized patients do not always know they are colonized and the results of such colonization is often unpredictable, with the MRSA laying virtually dormant until it achieves needed conditions for causing infection and transport to preferred areas for infection. A large population-based study looked at incidence of MRSA and simple S. aureus on a scale of healthy individuals in an attempt to figure out how prevalent colonization with and without infection is in the population.

The work was significant in that it made several important observations: The prevalence of colonization with S. aureus and with MRSA was 31.6% and 0.84%, respectively, in the noninstitutionalized U.S. population. People younger than 65 years of age, men, persons with less education, and persons with asthma were more likely to acquire S. aureus. Persons of black race and those of Mexican birth had lower risk for S. aureus colonization.

Persons 65 years of age or older, women, persons with diabetes, and those who were in long-term care in the past year were more likely to have MRSA colonization. Hispanic persons had statistically significantly less risk than white persons. Isolates of MRSA with staphylococcal chromosomal cassette mec type IV (which is often associated with community-associated MRSA) were statistically significantly more likely to be sensitive to erythromycin, clindamycin, and ciprofloxacin. (Graham, Lin & Larson, 2006, p.

318) The community-based study again indicates the need to screen and treat far more LTC residents than previously believed, as prevention may be one of the only resolutions to the wide spread nature of the problem and to the susceptibility for symptom causing colonization. Finally the most specific of the empirical studies I located with regard to the LTC population was Strausbaugh, Crossley, Nurse & Thrupp (1996) all members of a LTC committee that studied specific LTC patients and anti-microbial infection risks.

These researchers support the idea that the LTC population is at significant risk for MRSA as well as detailing a list of high risk demographics, "serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy." (1996, p.129) This work stresses the importance of prevention, screening and more stringent aseptic techniques among LTC staff, between patients and most importantly on hands and hard surfaces.

Methodology Research Design: This proposed study will be a prospective design associated with universal screening for nasal colonization of MRSA. All patients entering the LTCF will sign consent upon entry and will participate in a non-invasive nasal swab culture to determine if they are colonized with MRSA, any classic infections and all disease symptom fluids will also be cultured in those who show symptomology of MRSA upon.