Drugs & Aging

, Volume 10, Issue 3, pp 185–198 | Cite as

Methicillin-Resistant Staphylococcus aureus in Nursing Homes

Epidemiology, Prevention and Management
Review Article Drug Therapy

Summary

Infections caused by Staphylococcus aureus are a significant cause of morbidity and mortality in elderly persons in the community, hospitals and chronic care facilities. Methicillin-resistant S. aureus (MRSA) has become an important cause of severe infection in acutely ill patients in hospitals from diverse geographic areas. Whether MRSA has the same potential to spread and cause infection in nursing homes has only recently been explored. In the facilities studied, asymptomatic MRSA carriage has been common, but patients do not appear to have the same risk of acquiring the organism. The risk of MRSA colonisation appears to be associated with increasing debility, the presence of invasive devices or wounds, and increased overall mortality.

Most nursing home residents acquire MRSA during a hospital stay, not in the nursing home. Transmission of MRSA between nursing home residents may be less efficient than that seen among hospitalised patients. Once residents acquire MRSA, they remain persistently colonised for months to years. Many different MRSA strains circulate within nursing homes, probably reflecting the strains found in referring hospitals.

Fortunately, although MRSA colonisation is relatively common, rates of MRSA infection and attributable mortality appear to be low. However, the presence of MRSA in a facility might lead to fewer treatment options when infections do occur, with more adverse effects and increased costs. The routine use of surveillance cultures and antibacterials in an attempt to permanently eradicate MRSA from nursing home residents has not been successful, and resistance has quickly emerged. More importantly, nursing homes should utilise infection control practices that disrupt transmission by direct contact, thus preventing the potential spread of MRSA. Simple, inexpensive precautions, which emphasise handwashing and the use of gloves and gowns when soiling by patient body fluids is likely, are generally effective. Knowledge of the patient’s MRSA colonisation status is not necessary when these universal barrier precautions are applied to the care of all patients. If an increase in the rate of MRSA infections is documented, more intensive infection control measures should be implemented.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Strausbaugh LJ, Crossley KB, Nurse BA, et al. Antimicrobial resistance in long-term care facilities. Infect Control Hosp Epidemiol 1996; 17: 129–40PubMedCrossRefGoogle Scholar
  2. 2.
    Terpenning MS, Buggy BP, Kauffman CA. Hospital-acquired infective endocarditis. Arch Intern Med 1988; 148: 1601–3PubMedCrossRefGoogle Scholar
  3. 3.
    Terpenning MS, Buggy BP, Kauffman CA. Infective endocarditis: clinical features in young and elderly patients. Am J Med 1987; 83: 626–34PubMedCrossRefGoogle Scholar
  4. 4.
    Watanakunakorn C. Staphylococcus aureus endocarditis at a community teaching hospital, 1980 to 1991: an analysis of 106 cases. Arch Intern Med 1994; 154: 2330–5PubMedCrossRefGoogle Scholar
  5. 5.
    Jensen AG, Espersen F, Skinhoj P, et al. Staphylococcus meningitis: a review of 104 nationwide, consecutive cases. Arch Intern Med 1993; 153: 1902–8PubMedCrossRefGoogle Scholar
  6. 6.
    Espersen F, Frimodt-Moller N, Rosdahl VT, et al. Changing pattern of bone and joint infections due to Staphylococcus aureus: study of cases of bacteremia in Denmark, 1959–1988. Rev Infect Dis 1991; 13: 347–58PubMedCrossRefGoogle Scholar
  7. 7.
    McGuire NM, Kauffman CA. Septic arthritis in the elderly. J Am Geriatr Soc 1985; 33: 170–4PubMedGoogle Scholar
  8. 8.
    Emori TG, Banerjee SN, Culver DH, et al. Nosocomial infections in elderly patients in the United States, 1986–1990. Am J Med 1991; 91 Suppl. 3B: 289S–93SPubMedCrossRefGoogle Scholar
  9. 9.
    Spindel SJ, Strausbaugh LJ, Jacobson C. Infections caused by Staphylococcus aureus in a Veterans’ Affairs Nursing Home Care Unit: a 5-year experience. Infect Control Hosp Epidemiol 1995; 16: 217–23PubMedCrossRefGoogle Scholar
  10. 10.
    Beck-Sague C, Villarino E, Giuliano D, et al. Infectious diseases and death among nursing home residents: results of surveillance in 13 nursing homes. Infect Control Hosp Epidemiol 1994; 15: 494–6PubMedCrossRefGoogle Scholar
  11. 11.
    Standfast SJ, Michelsen PB, Baltch AL, et al. A prevalence survey of infections in a combined acute and long-term care hospital. Infect Control 1984; 5: 177–83PubMedGoogle Scholar
  12. 12.
    Jacobson C, Strausbaugh LJ. Incidence and impact of infection in a nursing home care unit. Am J Infect Control 1990; 18: 151–9PubMedCrossRefGoogle Scholar
  13. 13.
    Smith MA, Duke WM. A retrospective review of nosocomial infections in an acute rehabilitative and chronic population at a large skilled nursing facility. J Am Geriatr Soc 1994; 42: 45–9PubMedGoogle Scholar
  14. 14.
    Garb JL, Brown RB, Garb JR, et al. Differences in etiology of pneumonias in nursing home and community patients. JAMA 1978; 240: 2169–72PubMedCrossRefGoogle Scholar
  15. 15.
    Setia U, Serventi I, Lorenz P. Bacteremia in a long-term care facility: spectrum and mortality. Arch Intern Med 1984; 144: 1633–5PubMedCrossRefGoogle Scholar
  16. 16.
    Muder RR, Brennen C, Wagener MM, et al. Bacteremia in a longterm-care facility: a five-year prospective study of 163 consecutive episodes. Clin Infect Dis 1992; 14: 647–54PubMedCrossRefGoogle Scholar
  17. 17.
    Williams REO. Healthy carriage of Staphylococcus aureus: its prevalence and importance. Bacteriol Rev 1963; 27: 56–71PubMedGoogle Scholar
  18. 18.
    Noble WC, Valkenburg HA, Wolters CHL. Carriage of Staphylococcus aureus in random samples of a normal population. J Hyg (Camb) 1967; 65: 567–73CrossRefGoogle Scholar
  19. 19.
    Silberg SL, Neser WB, Blenden DC. Predisposition of the host to staphylococcal reinfection. Can J Public Health 1967; 58: 411–3PubMedGoogle Scholar
  20. 20.
    Noble WC, Somerville DA. Host factors and their effect on the normal flora. In: Rook A, editor. Microbiology of the human skin. London: W.B. Saunders Ltd, 1974: 284–301Google Scholar
  21. 21.
    Somerville DA. The normal flora of the skin in different age groups. Br J Dermatol 1969; 81: 248–57PubMedCrossRefGoogle Scholar
  22. 22.
    Phair JP, Kauffman CA, Bjornson A. Investigation of host defense mechanisms in the aged as determinants of nosocomial colonization and pneumonia. J Reticuloendothel Soc 1978; 23: 397–405PubMedGoogle Scholar
  23. 23.
    Zierdt CH. Long-term Staphylococcus carrier state in hospital patients. J Clin Microbiol 1982; 16: 517–20PubMedGoogle Scholar
  24. 24.
    Bradley SF, Terpenning MS, Ramsey MA, et al. Methicillinresistant Staphylococcus aureus: colonization and infection in a long-term care facility. Ann Intern Med 1991; 115: 417–22PubMedGoogle Scholar
  25. 25.
    Muder RR, Brennen C, Wagener MM, et al. Methicillin-resistant staphylococcal colonization and infection in a long-term care unit. Ann Intern Med 1991; 114: 107–12PubMedGoogle Scholar
  26. 26.
    Mulhausen PL, Harrell LJ, Weinberger M, et al. Contrasting methicillin-resistant Staphylococcus aureus colonization in Veterans Affairs and community nursing homes. Am J Med 1996; 100: 24–31PubMedCrossRefGoogle Scholar
  27. 27.
    Tuazon CU. Skin and skin structure infections in the patient at risk: carrier state of Staphylococcus aureus. Am J Med 1984; 76: 166–71PubMedCrossRefGoogle Scholar
  28. 28.
    Williams REO, Jevons MP, Shooter RA, et al. Nasal staphylococci and sepsis in hospital patients. BMJ 1959; 2: 658–62PubMedCrossRefGoogle Scholar
  29. 29.
    Miles AA, Williams REO, Clayton-Cooper B. The carriage of Staphylococcus (pyogenes) aureus in man and its relation to wound infection. J Pathol Bacteriol 1944; 56: 513–24CrossRefGoogle Scholar
  30. 30.
    Polakoff S, Richards IDG, Parker MT, et al. Nasal and skin carriage of Staphylococcus aureus by patients undergoing surgical operation. J Hyg (Camb) 1967; 65: 559–66CrossRefGoogle Scholar
  31. 31.
    Weinstein HJ. The relationship between the nasal-staphylococcal-carrier state and the incidence of postoperative infections. N Engl J Med 1959; 260: 1303–8PubMedCrossRefGoogle Scholar
  32. 32.
    Kluytmans JA, Mouton JW, Ijzerman EPF, et al. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis 1995; 171: 216–9PubMedCrossRefGoogle Scholar
  33. 33.
    Cookson BD. Epidemiology and control of nosocomial methicillin-resistant Staphylococcus aureus. Curr Opin Infect Dis 1991; 4: 530–5CrossRefGoogle Scholar
  34. 34.
    Panlilio AL, Culver DH, Gaynes RP, et al. Methicillin-resistant Staphylococcus aureus in US hospitals, 1975–1991. Infect Control Hosp Epidemiol 1992; 13: 582–6PubMedCrossRefGoogle Scholar
  35. 35.
    Barrett FF, McGehee RF, Finland M. Methicillin-resistant Staphylococcus aureus at Boston City Hospital. N Engl J Med 1968; 279: 441–8PubMedCrossRefGoogle Scholar
  36. 36.
    O’Toole RD, Drew WL, Dahlgren BJ, et al. An outbreak of methicillin-resistant Staphylococcus aureus infection: observations in hospital and nursing home. JAMA 1970; 213: 257–63PubMedCrossRefGoogle Scholar
  37. 37.
    Ward TT, Winn RE, Hartstein AL, et al. Observations relating to an inter-hospital outbreak of methicillin-resistant Staphylococcus aureus: role of antimicrobial therapy in infection control. Infect Control 1981; 2: 453–9PubMedGoogle Scholar
  38. 38.
    Haley RW, Hightower AW, Khabbaz RF, et al. The emergence of methicillin-resistant Staphylococcus aureus infections in United States hospitals: possible role of the house-staff-patient circuit. Ann Intern Med 1982; 97: 297–308PubMedGoogle Scholar
  39. 39.
    Hsu CCS, Macaluso CP, Special L, et al. High rate of methicillin resistance of Staphylococcus aureus isolated from hospitalized nursing home patients. Arch Intern Med 1988; 148: 569–70PubMedCrossRefGoogle Scholar
  40. 40.
    Thurn JR, Belongia EA, Crossley K. Methicillin-resistant Staphylococcus aureus in Minnesota nursing homes. J Am Geriatr Soc 1991; 39: 1105–9PubMedGoogle Scholar
  41. 41.
    Mylotte JM, Karuza J, Bentley DW. Methicillin-resistant Staphylococcus aureus: a questionnaire survey of 75 long-term care facilities in western New York. Infect Control Hosp Epidemiol 1992; 13: 711–8PubMedCrossRefGoogle Scholar
  42. 42.
    Woodrow S, Cream JJ, Russell Jones R. Tackling methicillinresistant Staphylococcus aureus. Lancet 1995; 346: 1225–6PubMedCrossRefGoogle Scholar
  43. 43.
    Fraise AP, Mitchell K, O’Brien S, et al. Methicillin-resistant Staphylococcus aureus in the community [letter]. Lancet 1995; 346: 850PubMedCrossRefGoogle Scholar
  44. 44.
    Goodall B, Tompkins DS. Nursing homes act as a reservoir [letter]. BMJ 1994; 308: 58PubMedGoogle Scholar
  45. 45.
    Bowman C, Mitchell J, Tillotson G. Methicillin-resistant Staphylococcus aureus in the community. Lancet 1995; 346: 513–4PubMedCrossRefGoogle Scholar
  46. 46.
    Rikitomi N, Nagatake T, Sakamoto T, et al. The role of MRSA (methicillin-resistant Staphylococcus aureus) adherence and colonization in the upper respiratory tract of geriatric patients in nosocomial pulmonary infections. Microbiol Immunol 1994; 38: 607–14PubMedGoogle Scholar
  47. 47.
    Pennington GR. Multiple antibiotic resistant Staphylococcus aureus in rehabilitation and extended care facilities: a non-problem. Aust N Z J Surg 1982; 52: 534–5CrossRefGoogle Scholar
  48. 48.
    Frenay HME, Peerbooms PGH, van Leeuwen WJ, et al. Nursing homes not a source of methicillin-resistant Staphylococcus aureus in the Netherlands. Clin Infect Dis 1994; 19: 213–4PubMedCrossRefGoogle Scholar
  49. 49.
    Aeilts GD, Sapico FL, Canawati HN, et al. Methicillin-resistant Staphylococcus aureus colonization and infection in a rehabilitation facility. J Clin Microbiol 1982; 16: 218–23PubMedGoogle Scholar
  50. 50.
    Storch GA, Radcliff JL, Meyer PL, et al. Methicillin-resistant Staphylococcus aureus in a nursing home. Infect Control 1987; 8: 24–9PubMedGoogle Scholar
  51. 51.
    Strausbaugh LJ, Jacobson C, Sewell DL, et al. Methicillin resistant Staphylococcus aureus in extended-care facilities: experiences in a Veterans Affairs nursing home and a review of the literature. Infect Control Hosp Epidemiol 1991; 12: 36–45PubMedCrossRefGoogle Scholar
  52. 52.
    Thomas JC, Bridge J, Waterman S, et al. Transmission and control of methicillin-resistant Staphylococcus aureus in a skilled nursing facility. Infect Control Hosp Epidemiol 1989; 10: 106–10PubMedCrossRefGoogle Scholar
  53. 53.
    Strausbaugh LJ, Jacobson C, Yost T. Methicillin-resistant Staphylococcus aureus in a nursing home and affiliated hospital: a four-year experience. Infect Control Hosp Epidemiol 1993; 14: 331–6PubMedCrossRefGoogle Scholar
  54. 54.
    Hsu CCS. Serial survey of methicillin-resistant Staphylococcus aureus nasal carriage among residents in a nursing home. Infect Control Hosp Epidemiol 1991; 12: 416–21PubMedCrossRefGoogle Scholar
  55. 55.
    Murphy S, Denman S, Bennett RG, et al. Methicillin-resistant Staphylococcus aureus colonization in a long-term care facility. J Am Geriatr Soc 1992; 40: 213–7PubMedGoogle Scholar
  56. 56.
    Feingold K, Siegler EL, Wu B, et al. Methicillin-resistant Staphylococcus aureus colonization in a new nursing home. Aging Clin Exp Res 1994; 6: 368–71Google Scholar
  57. 57.
    Terpenning MS, Bradley SF, Wan JY, et al. Colonization and infection with antibiotic-resistant bacteria in a long-term care facility. J Am Geriatr Soc 1994; 42: 1062–9PubMedGoogle Scholar
  58. 58.
    Strausbaugh LJ, Jacobson C, Sewell DL, et al. Antimicrobial therapy for methicillin-resistant Staphylococcus aureus colonization in residents and staff of a Veterans Affairs nursing home care unit. Infect Control Hosp Epidemiol 1992; 13: 151–9PubMedCrossRefGoogle Scholar
  59. 59.
    Kauffman CA, Terpenning MS, He X, et al. Attempts to eradicate methicillin-resistant Staphylococcus aureus from a long-term care facility with the use of mupirocin ointment. Am J Med 1993; 94: 371–8PubMedCrossRefGoogle Scholar
  60. 60.
    Sewell DL, Potter SA, Jacobson CM, et al. Sensitivity of surveillance cultures for the detection of methicillin-resistant Staphylococcus aureus in a nursing home care unit. Diagn Microbiol Infect Dis 1993; 17: 53–6PubMedCrossRefGoogle Scholar
  61. 61.
    Kono K, Arakawa K. Methicillin-resistant Staphylococcus aureus (MRSA) isolated in clinics and hospitals in the Fukuoka city area. J Hosp Infect 1995; 29: 265–73PubMedCrossRefGoogle Scholar
  62. 62.
    Hagiwara S, Miwa A, Yoshida M, et al. Methicillin-resistant Staphylococcus aureus: colonization and development of infection in patients with haematological disorders. Eur J Haematol 1995; 55: 267–71PubMedCrossRefGoogle Scholar
  63. 63.
    Peacock JE, Moorman DR, Wenzel RP, et al. Methicillin-resistant Staphylococcus aureus: microbiologic characteristics, antimicrobial susceptibilities, and assessment of virulence of an epidemic strain. J Infect Dis 1981; 144: 575–82PubMedCrossRefGoogle Scholar
  64. 64.
    Hershow RC, Khayr WF, Smith NL. A comparison of clinical virulence of nosocomially acquired methicillin-resistant and methicillin-sensitive Staphylococcus aureus infections in a university hospital. Infect Control Hosp Epidemiol 1992; 13: 587–93PubMedCrossRefGoogle Scholar
  65. 65.
    Pujol M, Pena C, Pallares R, et al. Nosocomial Staphylococcus aureus bacteremia among nasal carriers of methicillin-resistant and methicillin-susceptible strains. Am J Med 1996; 100: 509–16PubMedCrossRefGoogle Scholar
  66. 66.
    Jernigan JA, Clemence MA, Stott GA, et al. Control of methicillin-resistant Staphylococcus aureus at a University Hospital: one decade later. Infect Control Hosp Epidemiol 1995; 16: 686–96PubMedCrossRefGoogle Scholar
  67. 67.
    Chambers HE. Treatment of infection and colonization caused by methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 1991; 12: 29–35PubMedCrossRefGoogle Scholar
  68. 68.
    Mulligan ME, Murray-Leisure KA, Ribner BS, et al. Methicillin-resistant Staphylococcus aureus: a consensus review of the microbiology, pathogenesis, and epidemiology with implications for prevention and management. Am J Med 1993; 94: 313–28PubMedCrossRefGoogle Scholar
  69. 69.
    Lee Y-L, Gupta G, Cesario T, et al. Colonization by Staphylococcus aureus resistant to methicillin and ciprofloxacin during 20 months’ surveillance in a private skilled nursing facility. Infect Control Hosp Epidemiol 1996; 17: 649–53PubMedCrossRefGoogle Scholar
  70. 70.
    Noble WC, Virani Z, Cree RGA. Co-transfer of vancomycin and other resistance genes from Enterococcus faecalis NCTC 12201 to Staphylococcus aureus. FEMS Microbiol Lett 1992; 93: 195–8CrossRefGoogle Scholar
  71. 71.
    Ford CW, Hamel JC, Wilson DM, et al. In vivo activities of U-100592 and U-100766, novel oxazolidinone antimicrobial agents, against experimental bacterial infections. Antimicrob Agents Chemother 1996; 40: 1508–13PubMedGoogle Scholar
  72. 72.
    Kang SL, Rybak MJ. Pharmacodynamics of RP 59500 alone and in combination with vancomycin against Staphylococcus aureus in an in vitro-infected fibrin clot model. Antimicrob Agents Chemother 1995; 39: 1505–11PubMedCrossRefGoogle Scholar
  73. 73.
    Yu VL, Goetz A, Wagener M, et al. Staphylococcus aureus nasal carriage and infection in patients on hemodialysis: efficacy of antibiotic prophylaxis. N Engl J Med 1986; 315: 91–6PubMedCrossRefGoogle Scholar
  74. 74.
    Boelaert JR. Staphylococcus aureus infection in haemodialysis patients: mupirocin as a topical strategy against nasal carriage: a review. J Chemother 1994; 6 Suppl. 2: 19S–24SGoogle Scholar
  75. 75.
    Bradley SF. Effectiveness of mupirocin in the control of methicillin-resistant Staphylococcus aureus. Infection Med 1993; 10: 23–31Google Scholar
  76. 76.
    Walsh TJ, Standiford HC, Reboli AC, et al. Randomized double-blinded trial of rifampin with either novobiocin or trimethoprim-sulfamethoxazole against methicillin-resistant Staphylococcus aureus colonization: prevention of antimicrobial resistance and effect of host factors on outcome. Antimicrob Agents Chemother 1993; 37: 1334–42PubMedCrossRefGoogle Scholar
  77. 77.
    Bradley SF, Ramsey MA, Morton TM, et al. Mupirocin resistance: clinical and molecular epidemiology. Infect Control Hosp Epidemiol 1995; 16: 354–8PubMedCrossRefGoogle Scholar
  78. 78.
    Mylotte JM. Control of methicillin-resistant Staphylococcus aureus: the ambivalence persists. Infect Control Hosp Epidemiol 1994; 15: 73–7PubMedCrossRefGoogle Scholar
  79. 79.
    Boyce JM. Methicillin-resistant Staphylococcus aureus in hospitals and long-term care facilities: microbiology, epidemiology, and preventive measures. Infect Control Hosp Epidemiol 1992; 13: 725–37PubMedCrossRefGoogle Scholar
  80. 80.
    Boyce JM. Methicillin-resistant Staphylococcus aureus in nursing homes: putting the problem in perspective. Infect Control Hosp Epidemiol 1991; 12: 413–5PubMedCrossRefGoogle Scholar
  81. 81.
    Boyce JM, Jackson MM, Pugliese G, et al. Methicillin-resistant Staphylococcus aureus (MRSA): a briefing for acute care hospitals and nursing facilities. Infect Control Hosp Epidemiol 1994; 15: 105–15PubMedCrossRefGoogle Scholar
  82. 82.
    Nicolle LE, Strausbaugh LJ, Garibaldi RA. Infections and antibiotic resistance in nursing homes. Clin Microbiol Rev 1996; 9: 1–17PubMedGoogle Scholar
  83. 83.
    Sherertz RJ, Reagan DR, Hampton KD, et al. A cloud adult: the Staphylococcus aureus-virus interaction. Ann Intern Med 1996; 124: 539–47PubMedGoogle Scholar
  84. 84.
    Wenzel RP, Nettleman MD, Jones RN, et al. Methicillin-resistant Staphylococcus aureus: implications for the 1990s, and effective control measures. Am J Med 1991; 91 Suppl. 3B: 221S–7SPubMedCrossRefGoogle Scholar
  85. 85.
    Goetz AM, Muder RR. The problem of methicillin-resistant Staphylococcus aureus: a critical appraisal of the efficacy of infection control procedures with a suggested approach for infection control programs. Am J Infect Control 1992; 20: 80–4PubMedCrossRefGoogle Scholar
  86. 86.
    Cohen SH, Morita MM, Bradford M. A seven-year experience with methicillin-resistant Staphylococcus aureus. Am J Med 1991; 91 Suppl. 3B: 233S–7SPubMedCrossRefGoogle Scholar
  87. 87.
    Fazal BA, Telzak EE, Blum S, et al. Trends in the prevalence of methicillin-resistant Staphylococcus aureus associated with discontinuation of an isolation policy. Infect Control Hosp Epidemiol 1996; 17: 372–4PubMedCrossRefGoogle Scholar
  88. 88.
    Garner JS, the Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17: 53–80PubMedCrossRefGoogle Scholar
  89. 89.
    Smith PW. Infection control surveillance in long-term care facilities. Infect Control Hosp Epidemiol 1991; 12: 55–8PubMedCrossRefGoogle Scholar
  90. 90.
    Mylotte JM. Analysis of infection control surveillance data in a long-term-care facility: use of threshold testing. Infect Control Hosp Epidemiol 1996; 17: 101–7PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 1997

Authors and Affiliations

  1. 1.Divisions of Geriatric Medicine and Infectious Diseases, Geriatric Research Education and Clinical CenterVeterans Affairs Medical Center and University of Michigan Medical SchoolAnn ArborUSA
  2. 2.Veterans Affairs Medical CenterGRECC (IIG)Ann ArborUSA

Personalised recommendations