In the community, contact your doctor if you think you have an infection. Early treatment is very important.
- Wash your hands often, and always after changing the bandage or touching the infection. Use soap and water, or use an alcohol-based hand sanitizer.
- Do not treat the infection yourself, and do not pick or pop the sore.
- Cover the infection with dry bandages.
- Do not share personal items such as towels or razors.
- Wipe down non-washable equipment with an antibacterial solution, especially before being used by another person.
- Clean surfaces (counter tops, door knobs) with a standard disinfectant on a regular basis.
- Wash sheets, towels, and clothes with water and laundry detergent. Use a dryer to dry the items completely.
- If prescribed antibiotics, take all of the medicine as prescribed by your medical health professional. Finish your antibiotics as instructed, even if you feel better. If your healthcare professional tells you to stop taking antibiotics, return the unused medicine to your pharmacy.
- Do not share antibiotics with anyone, do not use leftover antibiotics, and do not use antibiotics that were prescribed to another person.
The prevention of MRSA infections in health care is based upon standard infection control precautions, which include routine practices, and contact precautions as required for all antibiotic-resistant organisms. Steps include, but are not limited to:
- Source Control
- Hand Hygiene
- Patient Care Equipment
- Education of Patient, Families and Visitors
- Handling of Laundry
- What is MRSA?
- Prevention & Treatment
- What is methicillin resistant Staphylococcus aureus?
- What is the difference between being colonized and being infected with MRSA?
- How does MRSA spread?
- Who is at risk for a MRSA infection?
- What are the symptoms of a MRSA infection?
- How is a MRSA infection treated?
- What isolation precautions are taken in the hospital if I have a MRSA infection?
- What precautions should I take at home if I have a MRSA infection?
- Where can I get more information about MRSA?
- Methicillin Resistant Staphylococcus aureus Prostatic Abscess with Bacteremia
- Isolation of Staphylococcus aureus from the Urinary Tract: Association of Isolation with Symptomatic Urinary Tract Infection and Subsequent Staphylococcal Bacteremia
- Materials and Methods
- MRSA in the Bladder
- All you need to know about MRSA
- MRSA UTI Prevention – 5 Contributing Factors to Developing a MRSA UTI in a Nursing Home
- Learning about MRSA: A guide for Patients
- About MRSA
- MRSA Transmission
- MRSA Diagnosis
- Treating MRSA
- Preventing the Spread of MRSA
- Caring for Yourself
- Changing Bandages
- Important Note:
- Things to remember about having MRSA:
Contact precautions should be used with patients with known or suspected infections. It is not necessary to wait for testing to confirm a diagnosis. Use contact precautions (e.g., procedures to prevent droplet or aerosols). Post signs at the entrance to patient area. Single patient rooms may be used with designated toilets and sinks. Separating patients by 2 metres may also be used when a respiratory infection is present.
Hand hygiene can be performed with an alcohol-based hand rub or with soap and water. Alcohol-based hand rub is used at the point of care in healthcare settings when hands are not visibly soiled. If hands are visibly soiled, wash with soap and water.
Wear gloves when touching blood, body fluids and contaminated items. Remove gloves between patient contacts and clean hands immediately.
Wear a mask and eye protection, or face shields, or masks with a visor attachment during procedures that are likely to generate splashes or droplets of respiratory secretions, blood, or body fluids.
Long-sleeved cuffed gowns are not routine, but may be needed in specific situations. Follow your organization’s policies.
Patient Care Equipment
Appropriate cleaning, disinfection and sterilization of patient care equipment and rooms are important in limiting the transmission of organisms. Equipment may be dedicated to a single patient when possible. Surfaces that are likely to be touched or used should be cleaned and disinfected more frequently (e.g., bedrails, tables, call bells, door knobs, bathroom facilities, etc.).
Education of Patient, Families and Visitors
All people involved should be educated about the importance of the precautions being used to help prevent the transmission of the disease. Hand hygiene is particularly important.
Handling of Laundry
In healthcare settings, while care should be taken when handling soiled linen, special handling of linen from patients with additional precautions is not required. When at home, linens, wash towels and bed linens in a washing machine set to the hottest water setting (with added bleach, if possible) and dry them in a hot dryer. Wash gym and athletic clothes after each wearing.
For further information refer to Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings (2107) from the Public Health Agency of Canada.
See the OSH Answers on Antibiotic/Antimicrobial Resistance in Bacteria and Organisms for more information.
Doctors want to identify MRSA in urine as soon as possible. This antibiotic-resistant urinary tract infection can become life-threatening, especially in aged persons.
Symptoms can include swollen and painful red bumps that leak fluid and resemble spider bites or pimples. If you or a loved one is experiencing these symptoms, schedule an appointment with a doctor.
If diagnosed, there are several treatment options. These include draining the abscesses and administering less common forms of antibiotics.
Hospitals and other patient-care facilities are the most common locations of these infections.
What is MRSA?
MRSA stands for “methicillin-resistant Staphylococcus aureus.” It is also sometimes known as a “mercer infection.”
Staphylococcus aureus, or “staph,” is an infection. The infection is found almost anywhere. Staph bacteria are one of the most common causes of skin infections in the United States.
This bacterium is typically found on the skin and in the nose of healthy people. We can present staph bacteria without having a staph infection. This is called “colonization.” The bacteria have colonized a host, but the bacteria are not harming anything.
However, staph bacteria can cause minor infections such as pimples and boils. In other cases, staph can lead to more serious infections.
MRSA is a staph infection that is resistant to the most common antibiotics. It does not respond to the antibiotics that were once able to destroy it.
For years, doctors over-prescribed antibiotics. They were prescribed for the flu, colds, and viral infections. This contributed to the rise of drug-resistant bacteria. The bacteria evolved to resist the antibiotics.
However, MRSA is not resistant to all antibiotics.
The Centers for Disease Control and Prevention estimates that less than 2% of the population is colonized by MRSA bacteria.
The bacteria are contagious and mostly spread through skin-to-skin contact. MRSA can also spread to you if you touch objects that have the bacteria on them.
Resistance and Prevalence
According to the Centers for Disease Control and Prevention, MRSA is resistant to the most common antibiotics. These common antibiotics include:
You can get MRSA urinary tract infections and skin infections in different places. They can either be community-acquired (CA-MRSA) or hospital-acquired (HA-MRSA).
HA-MRSA in nursing homes is of national and global concern. Staph infections in elderly persons can be particularly dangerous. Antibiotic-resistant staph infections also have a higher mortality rate.
CA-MRSA is a newer problem. It can be acquired in athletic facilities, dormitories, schools, daycares, military barracks, prisons, or other crowded living spaces. Poor hygiene and skin-to-skin contact increase the risk of MRSA infections.
HA-MRSA is more likely to present itself in the elderly. CA-MRSA is more likely to present itself in the young.
You may notice a range of symptoms before a doctor finds MRSA in urine or on your skin. If you see any of these symptoms occur in yourself or a loved one, contact a doctor immediately.
MRSA infections may cause you to experience a fever.
For skin infections, MRSA symptoms first appear as swollen or painful red bumps. These bumps may look similar to pimples or spider bites. A misdiagnosis of a spider bite is common for many MRSA infections.
The area may be warm to the touch and full of pus or other draining fluids.
If untreated, these red bumps may become painful abscesses in your skin. At this point, they may require surgical draining. Only a medical professional should drain an abscess or a boil.
If the bacteria spreads through a cut or another open wound, the infection may sink below the surface of the skin. It may spread to internal organs. In this case, MRSA infections can cause serious, life-threatening problems.
These more serious infections might spread into bones, joints, surgical wounds, bloodstreams, heart valves, or lungs.
Antibiotic-resistant infections such as MRSA are known as a worldwide threat to public health. The ability to resist the effect of antibiotics keeps people sick longer and increases the risk of death.
According to the World Health Organization, people suffering from an MRSA infection are estimated to be 64% more likely to die than people with a non-resistant staph infection.
For this reason, it is important that doctors identify these infections early. This is especially true of MRSA in elderly patients. Older individuals tend to have weaker immune systems. They are more susceptible to higher mortality rates.
Doctors identify MRSA in urine and on the skin using a test called an MRSA culture. This test looks for MRSA bacteria in fluid samples taken from the patient.
In addition to urine samples, doctors may take samples from open wounds, sputum in the throat, or blood. As MRSA presents itself in several different localized areas, your MRSA culture will depend on the location of the infection.
The fluid sample combines with special nutrients that prompt any MRSA bacteria to grow. The test can take up to 48 hours. After 48 hours, the results should be conclusive.
If you or a loved one are experiencing any of the noted symptoms of an MRSA infection, ask your doctor about being tested. You will need proper diagnosis before beginning treatment.
Prevention & Treatment
Antibiotic-resistant infections pose a greater treatment challenge than antibiotic-responsive infections. MRSA costs more to treat and results in a higher mortality rate.
As a result, caregivers attempt to prevent the disease from infecting patients as the first line of defense.
The Centers for Disease Control and Prevention estimated that two million illnesses and 23,000 deaths are caused by drug-resistant bacteria every year. These numbers only account for illnesses and deaths in the United States.
In 2011, 80,000 invasive MRSA infections and over 11,000 related deaths occurred.
In 2014, the President Barack Obama of the United States of America issued an executive order on combating antibiotic-resistant bacteria. Among other things, this order developed a task force for combating this kind of bacteria.
The task force resulted in The National Action Plan for Combating Antibiotic-Resistant Bacteria.
The main goals of the Action Plan were: to slow the emergence of antibiotic-resistant bacteria and to prevent the spread of these infections.
Infection control is vital to halting the spread of the disease in hospitals. Most prevention methods are inexpensive. They emphasize wearing gloves, washing hands, and covering wounds.
The Centers for Disease Control and Prevention outlines standard precautions for preventing the spread of MRSA:
- Practice good hand hygiene
- Wear gloves when encountering bodily fluids
- Use personal protective equipment (PPE) on the mouth, nose, and eyes
- Wear a gown during procedures and patient-care activities
- Use appropriate handling of soiled patient care equipment
- Use appropriate handling of laundry in treatment facilities
If you are suffering from a minor MRSA infection, you should still be able to go to work unless directed otherwise by a doctor. It’s important to cover any wounds, abscesses, or boils.
Between 2001 and 2005, the overall rate of invasive MRSA infections dropped 31%. This was predominantly a result of caregivers following appropriate medical procedures.
In 2016, the Centers for Disease Control and Prevention estimated 72,444 invasive MRSA infections in the country.
More information on preventing the spread of infection can be found here:
In the case of MRSA in the urine, there have been several studies on reducing resistance to antibiotics. Some studies have found that MRSA remains susceptible to antibiotics including:
The National Institute of Allergy and Infectious Diseases identifies treatment options for MRSA skin infections. These options can include draining the skin boils or abscesses. This is the first line of treatment.
MRSA resists antibiotics. Therefore, treatment providers will avoid treating you or your loved one with beta-lactam biotics. This class of antibiotics is deemed ineffective in killing the staph bacteria.
In the cases of severe infection, doctors may administer vancomycin intravenously. Vancomycin is an antibiotic. It is recommended for treating the symptoms of MRSA including skin infections, bloodstream infections, bone infections, and meningitis.
Isolation placement is common for patients who contract HA-MRSA in a medical facility. Since MRSA is contagious, medical facilities are at high risk for spreading the infection.
In the cases of nursing homes, it’s particularly important to isolate anyone diagnosed with MRSA. If the infection should spread, many nursing home residents may be facing a life-threatening staph infection.
The presence of MRSA in a nursing home could lead to fewer treatment options. When infections do occur, they may be accompanied by more adverse effects and increased costs.
When doctors test for MRSA in urine or on the skin, they are giving their patients the best possible chance for treatment. If the symptoms are identified and treated early, it reduces the risk of life-threatening illness.
If you or a loved one has suffered from MRSA in the past, share your personal experiences in the comments.
This information explains methicillin resistant Staphylococcus aureus (MRSA), including how it spreads and how infections are treated.
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What is methicillin resistant Staphylococcus aureus?
Staphylococcus (staph) is a type of bacteria that naturally exist in the environment, including on people’s skin. Methicillin resistant Staphylococcus aureus (MRSA) is a type of staph bacteria that is resistant to certain antibiotics. This means that some treatments won’t work or may be less effective.
MRSA can cause many illnesses, including:
- Urinary tract infections (UTIs)
- Blood infections
- Wound or skin infections
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What is the difference between being colonized and being infected with MRSA?
A person can be either colonized or infected with MRSA. If a person is colonized, it means that the bacteria is present on their skin or in their body, but they have no symptoms. If a person is infected, it means that the bacteria is present on their skin or in their body and it’s causing symptoms.
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How does MRSA spread?
Most MRSA infections are spread by direct contact with an infected person’s bodily fluids, such as blood, drainage from a wound, urine (pee), bowel movements (poop, or sputum (phlegm). It can also be spread by touching equipment or surfaces that have come in contact with the bacteria. Casual contact, such as touching or hugging, doesn’t spread MRSA.
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Who is at risk for a MRSA infection?
You’re more likely to get a MRSA infection if you:
- Are older
- Have weakened immune systems
- Have chronic illnesses, such as cancer or diabetes
- Have been treated with antibiotics in the past
- Have had a recent surgery
- Have had repeated or long hospital stays
- Have open wounds or sores
- Have tubes or drains in the body
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What are the symptoms of a MRSA infection?
Your symptoms will depend on where the infection is and what type of infection you have.
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How is a MRSA infection treated?
MRSA infections are treated with antibiotics that are not resistant to the bacteria.
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What isolation precautions are taken in the hospital if I have a MRSA infection?
Isolation precautions are steps we take to stop infections from spreading from person to person. If you’re diagnosed with or exposed to a MRSA infection while you’re in the hospital:
- You will be placed in a private room.
- A sign will be posted on your door telling all staff and visitors to clean their hands with soap and water or an alcohol-based hand sanitizer before going into and after leaving your room.
- All staff and visitors who enter your room must wear a yellow gown and gloves. These are available outside of your room and can be disposed of inside your room.
- If you leave your room for tests, you must wear a yellow gown and gloves or be covered with a clean sheet.
- If you leave your room to walk around the unit, you must wear a yellow gown and gloves.
- You will not be able to go to the following areas of the hospital:
- Pantry on your unit
- Recreation center on M15
- Pediatric recreation areas on M9
- Main lobby
- Any other public area of the hospital
- You can have art or massage therapy in your room while following isolation precautions.
Your doctor will let you know when you can stop following these precautions. This will be after you’re treated and no longer have symptoms.
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What precautions should I take at home if I have a MRSA infection?
Be sure to do the following at home:
- Wash your hands frequently with soap and water, especially after using the bathroom.
- Wash your hands after having contact with blood, urine, or drainage from a wound.
- Use a disinfectant (such as Clorox® or Lysol®) to wipe any surface that may have been contaminated with the germ, such as your doorknob.
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Where can I get more information about MRSA?
If you have any questions, talk with your doctor or nurse. You can also visit the following websites for more information:
Centers for Disease Control and Prevention New York State Department of Health Back to top Arrow (up) icon.
Methicillin Resistant Staphylococcus aureus Prostatic Abscess with Bacteremia
Prostatic abscess is traditionally considered a rare disease that is caused by Gram-negative bacteria. Methicillin resistant Staphylococcus aureus (MRSA) has recently emerged as an important cause of prostatic abscesses. Symptoms are nonspecific and include dysuria, urinary frequency, fever, chills, and perineal and low back pain. Morbidity and mortality increase with delays in identification and proper treatment. We present two cases of community acquired MRSA prostatic abscesses with bacteremia. One of these cases may be the first reported septic shock fatality resulting from a prostatic abscess source in an immunocompetent patient. As the number of community acquired MRSA bacteremia cases increases, this potential site of infection should be recognized.
There is no clear consensus about the incidence of prostate abscess, but it is thought to be a rare but potentially fatal disease . Typical symptoms include dysuria, frequency, fever, chills, and perineal and low back pain . When clinically suspected, diagnostic workup includes cultures and imaging, and treatment includes broad spectrum antibiotics and drainage . Escherichia coli and enteric organisms account for the majority of prostate infections. Staphylococcus aureus is reported much less commonly , while methicillin resistant Staphylococcus aureus (MRSA) is considered rare . Since 2000, multiple cases of hospital and community acquired MRSA prostatic abscess have been reported (Table 1) .
|TURP: transurethral resection of prostate.|
Table 1 Clinical characteristics of patients with MRSA prostatic abscess.
We report two cases of community acquired MRSA prostatic abscess with bacteremia at the same medical center within a 2-year time interval. These cases are unique because they were young and healthy, without typical risk factors, and had particularly severe clinical illness. To our knowledge, the first case may be the first reported immunocompetent male dying of septic shock from a primary community acquired MRSA prostatic abscess.
Case 1. A 47-year-old male with past medical history of partial hypospadias with urethral stricture presented with a one-week history of diffuse myalgias, dry cough, anorexia, dyspnea, fever, and chills. He had been recently treated with penicillin for a presumed penile shaft furuncle. He was brought to the emergency department after becoming more somnolent and dyspneic. His wife reported that he had not complained of hematuria, abdominal pain, or dysuria. Upon presentation he was hypotensive and required intubation for respiratory failure. Vancomycin, piperacillin/tazobactam, stress dose hydrocortisone, and norepinephrine infusion were initiated. Despite maximal support, he expired 27 hours after admission. Negative diagnostic studies included Clostridium difficile toxin, nasal MRSA swab, nasal viral swab, sputum culture, influenza, respiratory syncytial virus, HIV 1/2, and Legionella. The two admission blood cultures and urine culture were positive for MRSA sensitive to clindamycin, gentamicin, linezolid, quinupristin/dalfopristin, tetracycline, trimethoprim/sulfamethoxazole, and vancomycin, with resistance to cefazolin, erythromycin, methicillin, oxacillin, and penicillin G.
At the time of death, the working diagnosis was septic shock secondary to pneumonia. At autopsy, the lungs showed multiple septic pulmonary infarcts (Figure 1) with extensive bronchopneumonia. The mitral valve had 2 forms of bacterial vegetation. The spleen was enlarged (600 g) with a recent infarct. The right kidney also had an infarct and the left kidney had focal pyelonephritis. The prostate was asymmetric, larger on the left, with cavitations, necrotic tissue, and grossly purulent exudate (Figure 2). The prostatic venous plexus was thrombosed. The bladder did not have any pseudodiverticulosis or trabeculation and the ureters were unremarkable.
Alveolar tissue with septic emboli. Culture positive for MRSA.
Prostatic tissue with polymorphonuclear cells. Culture positive for MRSA.
The final cause of death was septic shock from community acquired MRSA. The pathologist excluded the penile furuncle as the source of the MRSA bacteremia since only penile fibrous tissue was present (Figure 3), with no bacterial growth or suppurative fluid. The pathologist opined that the prostate gland was the primary source of bacteremia and metastatic infection of the lung, heart, and other organs. This opinion was based on histological evidence of more temporally advanced prostatic suppurative inflammation compared to the other affected organs. Postmortem bacterial cultures grew MRSA from the lung, heart, kidney, and prostate.
Penile lesion with chronic inflammatory cells. Culture negative for MRSA.
Case 2. A 31-year-old male with past medical history of sickle-beta thalassemia presented to the hospital with three days of left-sided pleuritic chest pain, fevers, rigors, and fatigue. He had received ciprofloxacin for complaints of dysuria 3 days previously. Physical examination showed a very tender prostate, clear lung sounds, and no cardiac murmurs. Urinalysis showed trace leukocyte esterase, 3 white blood cells, and 1 red blood cell. White blood cell count was 10,200 cells/Ul. A CT angiogram showed a patchy right middle lobe opacity and mediastinal adenopathy, without pulmonary emboli. He was treated with vancomycin and piperacillin/tazobactam. The two sets of blood cultures obtained on admission grew MRSA sensitive to clindamycin, gentamicin, linezolid, quinupristin/dalfopristin, tetracycline, trimethoprim/sulfamethoxazole, and vancomycin, with resistance to cefazolin, erythromycin, methicillin, oxacillin, and penicillin G.
His electrocardiogram suggested pericarditis, prompting an echocardiogram showing possible intra- and extramyocardial masses, no valvular vegetation, and a pericardial effusion without tamponade. Cardiac MRI showed minimal focal enhancement and a large exudative pericardial effusion with evidence of mild constriction. Pericardial fluid was not obtained. After what had been learned from the first case, a CT of the abdomen and pelvis revealed a 2.3 × 2.2 cm prostatic abscess (Figure 4). The abscess was transrectally drained and cultures grew MRSA. The patient was discharged home on intravenous vancomycin.
(b) Figure 4
(a) Initial CT scan (left) showing 2.3 cm prostate abscess in the right gland (red arrow). (b) Repeat CT scan (right) 1 week later showed larger and multiple cystic fluid collections in the prostate gland (blue arrow).
Three days later he again presented with fever, rigors, hematuria, pyuria, and left flank pain. A repeat CT showed worsening prostatic abscess (Figure 4). Blood cultures remained negative. Vancomycin was switched to daptomycin and a transurethral prostate resection (TURP) with abscess drainage was performed. His fever and other symptoms resolved and he completed an outpatient course of daptomycin and trimethoprim/sulfamethoxazole.
Eighteen cases of hospital and community acquired MRSA related prostate infections have been reported worldwide, including our two cases from a single medical center (Table 1) . Of the total reported cases, the age ranges from 29 to 77 years. Sixteen of the patients had genitourinary (GU) complaints, seventeen had prostatic abscesses on imaging or autopsy, sixteen had bacteremia, ten had diabetes, and two had AIDS (Table 1) . The first reported fatal case was in a patient with AIDS , so to our knowledge our first patient is the only reported instance of an immunocompetent host succumbing to this infection.
There are no established treatment guidelines for prostatic abscess. Of the other reported cases, two were successfully treated with antibiotics alone, and the other fourteen required drainage and antibiotic regimens that included vancomycin, daptomycin, doxycycline, rifampin, sulfamethoxazole/trimethoprim, and nafcillin (Table 1) . Linezolid is an acceptable treatment option for MRSA prostate and urinary tract infections but was not used in any of these reported cases . Our first case highlights the potential virulence of this infection and illustrates why early antibiotics and drainage are critical in severe cases.
Common risk factors and mechanisms for prostate infections include obstructive uropathy with retrograde flow of urine, straddle injury, urethral foreign bodies (e.g., chronic indwelling catheters and lower GU tract instrumentation), prostatitis, HIV infection, diabetes mellitus, immunodeficiency states, and bacteremia . Our first patient had a urethral stricture, but autopsy showed no signs of obstructive changes in the bladder. We speculate that his history of a penile furuncle led to the prostatic abscess with subsequent development of acute bacterial endocarditis. The pathologist’s temporal assessment favors this speculative conclusion. If correct, it is possible that earlier, more aggressive prostate abscess treatment may have been lifesaving. Despite the postmortem findings, we cannot rule out the possibility that the penile furuncle was the source of bloodstream infection and endocarditis, with subsequent metastatic prostatic infection.
Hematogenous seeding of the prostate was more likely in our second patient, who did not have any of the common prostatic abscess risk factors . Once seeded with bacteria, prostatic abscess development is facilitated by diagnostic delay, impaired host defense , infection with organisms prone to abscess formation (e.g., Staphylococcus aureus) , inadequate antimicrobial therapy , or poor antibiotic penetration into the prostate .
Both hospital- and community-acquired MRSA variants are capable of infecting the prostate. In 2000, a new strain of community acquired MRSA, USA300 Panton-Valentine leukocidin (PVL) positive (MRSA 300), was reported. PVL is a potent toxin that confers greater virulence, increasing the likelihood of necrotizing pneumonia and greater complications of bacteremia including endocarditis, osteomyelitis, soft tissue infection, renal abscess, and now prostate abscess . MRSA 300 was identified to be the causative organism in two of the reported cases . We do not know if either of our patients had this MRSA strain.
Methicillin resistant Staphylococcus aureus is not commonly found in the urine with one study isolating 0.8% of 9,985 urine samples with MRSA . Risk factors for MRSA in the urine, similar to prostate infections, include increased age, diabetes, hospital exposure, catheter use, genitourinary abnormalities, bacteremia, and pyelonephritis . Identification of MRSA in the urine should prompt a search for endovascular infection .
In summary, we present two cases of severe MRSA-induced prostatic abscess and review the published literature. We speculate that our first patient died from a prostatic abscess that subsequently seeded the bloodstream, causing acute bacterial endocarditis, widely metastatic infection, and septic shock. To our knowledge, this is the first reported case of fatal septic shock suspected to originate from a prostatic abscess in an immunocompetent host. As cases of MRSA bacteremia increase, physicians need to consider the prostate as a site of primary or persistent infection. The mainstays of treatment are early identification, appropriate antibiotics, and surgical drainage. Greater awareness of MRSA prostate infection should increase the likelihood that these treatments are promptly administered.
Conflict of Interests
The authors declare that there is no conflict of interests.
S. aureus is a common pathogen found both in the community and in hospitals. It is, however, a relatively uncommon cause of urinary tract infection in the general population , although isolation of S. aureus from urine samples is often secondary to staphylococcal bacteremia arising elsewhere. S. aureus is the most prominent pathogen in terms of total numbers of infections and is an important nosocomial pathogen with a high degree of nosocomial transmission . This is complicated by an increasing prevalence (from 2% in 1974 to as high as 64% in 2002) of methicillin-resistant S. aureus among nosocomial isolates , which is similar to the findings of our study, which showed an increase in MRSA infection (Fig. 1).
Increase of methicillin-resistant Staphylococcus aureus (MRSA) infections during the time period from 2004 to 2009. Furthermore the exponential trend (black line) is delineated on the diagram.
Over the past 20 years, MRSA has emerged as an important cause of nosocomial bacteremia, and there has been a significant increase in the incidence of MRSA infections. Methicillin resistance is an additional risk factor for increased morbidity and mortality in patients with acquired S. aureus infections . Most urinary tract infections caused by MRSA are HA-MRSA infections. Generally, these patients are asymptomatic, but in the case of a weakened general condition, a symptomatic MRSA infection can worsen the patient’s status considerably and require treatment.
In relation to increasing life expectancy, patients with urinary problems, indwelling catheters, and limited mobility are in need of caution for determining sources for MRSA . In this study, we found MRSA in 89.7% (n=218) of patients with catheters. The rate of infection in patients with indwelling catheters was 76.1% (n=185), and 13.6% (n=33) were patients with urinary catheters in the intensive care unit. Catheter-associated infection had a density rate of approximately 18 days. Of these infections, 10.3% (n=25) were in voided specimens.
The clinical presentation of MRSA infection is often unspectacular because the patients are asymptomatic. Often, MRSA-positive cultures are found during routine changes of indwelling catheters and no therapy is necessary. Furthermore, the symptomatic clinical differentiation between urinary MRSA and MRSA from other sites, like the bloodstream, is difficult. In this case, however, independent of the source of MRSA, treatment is implicated. The intensive care patients with symptomatic MRSA infection had septicemia in 9 cases (27.3%) because of a urinary tract infection combined with additional enterobacteria. In these patients, antibiotic combination therapy was required. In all nine cases, gentamicin was one part of the combination; the second part depended on the finding of the bacterial culture. The patients presented with fever, increased inflammatory parameters in blood, and significantly reduced general condition. In these patients, the aim is to remove any devices as soon as possible.
In patients with MRSA-induced bacteremia, a positive urine culture is typically attributed to ascending infection or to hematogenous spread. Predictors of a positive urine culture for MRSA include indwelling catheters, urinary tract obstruction, and surgery .
Contrary to HA-MRSA, CA-MRSA urinary tract infections offer clinical symptoms such as dysuria and pollakisuria. Of the 5.7% of the study population with CA-MRSA, no MRSA source was found other than the urinary sample. Possible reasons for the increase in community-acquired infections are (1) the lateral dissemination of MRSA from the hospital to the community from discharged patients diagnosed with MRSA, and (2) the discontinuation of therapy and missing follow-ups. Many strains of MRSA are frequently multi-antibiotic resistant . Previous studies have suggested that MRSA infections are associated with prolonged hospitalization and increased mortality when compared with infections due to methicillin-susceptible S. aureus. Such comparisons may be confounded by an increased incidence of comorbid conditions among patients with MRSA infections, although the therapeutic options for patients with MRSA infections are limited. One option is selective intravenous therapy, because other common oral antimicrobials, including fluoroquinolones and third-generation cephalosporins, are ineffective against MRSA .
In this study, we characterized the epidemiology of MRSA from urine cultures within the first 24 hours of hospital admission. The incidence of MRSA bacteriuria at hospital admission increased over the study period. As expected, MRSA showed complete resistance to a significant number of antimicrobial substances throughout the study. This was more common in the case of frequently used antibiotics such as aminopenicillin, cephalosporins, carbapenem, penicillin G, β-lactamase, and isoxazolyl penicillin.
Widespread use of broad-spectrum antimicrobial agents and the limited potency of some agents have exerted heavy selection pressures in hospital environments. Therefore, the re-emergence of resistant gram-positive pathogens, particularly MRSA, is of increasing concern .
It is difficult to eradicate MRSA in patients with indwelling catheters and stents because these bacteria form biofilms, and staphylococcal cells embedded in a biofilm or in microcolonies are conspicuously more resistant to antibiotic substances . Furthermore, all involved people (i.e., medical and nursing staff, family members, and friends) can be easily contaminated and can be the link from HA- to CA-MRSA.
Decrease in the methicillin-resistant Staphylococcus aureus resistance within a time period of 6 years on the basis of amikacin use.
Decrease in the methicillin-resistant Staphylococcus aureus resistance on the basis of gentamicin use within the same period as amikacin in Fig. 2.
As a potential source of resistance to antimicrobial agents, the noncritical use of antibiotics is supported. Even in viral respiratory infections, antibiotics were prescribed in this study. Furthermore, patient use of extant drugs for treating previous infections as well as premature termination of therapy, contrary to the recommendations, contribute to the development of resistance.
Infection control measures and screening of the nursing staff, as well as proper hand hygiene and surveillance cultures, may help to arrest the spread of MRSA in hospital settings . An antibiotic policy may prevent MRSA and other bacteria from developing further resistance. Monitoring of susceptibility patterns of MRSA may be helpful in decreasing the prevalence of MRSA and antibiotic resistance .
Furthermore, a postdischarge collection of a self-report survey of patients who had been screened and the potential beneficial impact of MRSA screening for patients and the wider community would not reduce the infection rate but would allow an earlier and more specific therapy regimen if necessary. Furthermore, such surveys can be used to give information to involved persons about how to take appropriate hygiene measures .
Isolation of Staphylococcus aureus from the Urinary Tract: Association of Isolation with Symptomatic Urinary Tract Infection and Subsequent Staphylococcal Bacteremia
Background. Staphylococcus aureus is frequently isolated from urine samples obtained from long-term care patients. The significance of staphylococcal bacteriuria is uncertain. We hypothesized that S. aureus is a urinary pathogen and that colonized urine could be a source of future staphylococcal infection.
Methods. We performed a cohort study of 102 patients at a long-term care Veterans Affairs facility for whom S. aureus had been isolated from clinical urine culture. Patients were observed via urine and nasal cultures that were performed every 2 months. We determined the occurrence of (1) symptomatic urinary tract infection concurrent with isolation of S. aureus (by predetermined criteria), (2) staphylococcal bacteremia concomitant with isolation of S. aureus from urine, and (3) subsequent episodes of staphylococcal infection.
Results. of 102 patients, 82% had undergone recent urinary catheterization. Thirty-three percent of patients had symptomatic urinary tract infection at the time of initial isolation of S. aureus, and 13% were bacteremic. Eight-six percent of the initial urine isolates were methicillin-resistant S. aureus. Seventy-one patients had follow-up culture data; 58% of cultures were positive for S. aureus at ⩾ 2 months (median duration of staphylococcal bacteriuria, 4.3 months). Sixteen patients had subsequent staphylococcal infections, occurring up to 12 months after initial isolation of S. aureus; 8 late-onset infections were bacteremic. In 5 of 8 patients, the late blood isolate was found to have matched the initial urine isolate by pulsed-field gel electrophoresis typing.
Conclusions. S. aureus is a cause of urinary tract infection among patients with urinary tract catheterization. The majority of isolates are methicillin-resistant S. aureus. S. aureus bacteriuria can lead to subsequent invasive infection. The efficacy of antistaphylococcal therapy in preventing late-onset staphylococcal infection in patients with persistent staphylococcal bacteriuria should be tested in controlled trials.
Staphylococcus aureus is a relatively uncommon cause of urinary tract infection in the general population . Although isolation of S. aureus from urine samples is often secondary to staphylococcal bacteremia arising elsewhere (e.g., in cases of endocarditis) , in certain patients, S. aureus causes ascending urinary tract colonization and infection. Urinary tract instrumentation and the presence of an indwelling catheter increase the risk of S. aureus carriage in the urinary tract . The majority of cases of S. aureus bacteriuria are not associated with symptoms of urinary tract infection . Because bacteriuria nearly universally occurs concomitantly with long-term urinary catheterization , the clinical significance of isolation of S. aureus from the urine is undefined in such patients. Clear differentiation between asymptomatic bacteriuria and clinical urinary tract infection is difficult in the elderly population . Although urinary S. aureus may be the source of staphylococcal bacteremia , the proportion of patients with chronic S. aureus bacteriuria who subsequently become bacteremic is unknown.
After identifying 2 patients who developed S. aureus bacteremia subsequent to staphylococcal colonization of the urinary tract, we undertook a longitudinal study of patients identified as having S. aureus bacteriuria during the course of routine infection-control surveillance to determine the clinical significance of S. aureus bacteriuria, the association between bacteriuria and bacteremia, and the long-term outcome of staphylococcal urinary colonization. We postulated that (1) S. aureus urinary tract infection was a true clinical entity, and (2) staphylococcal bacteremia could result from urinary tract colonization with S. aureus.
Materials and Methods
Patients were identified from microbiology laboratory reports by infection-control practitioners during routine surveillance activities. All patients for whom S. aureus was isolated from urine cultures ordered by the patients’ physicians for clinical indications were entered into a prospective, observational study. Nares cultures were obtained at entry. Clinical isolates of S. aureus were identified by the Vitek system (bioMérieux) using standard criteria. Methicillin resistance was confirmed by plating on Mueller-Hinton agar supplemented with 4% NaCl and oxacillin, 6 µ g/mL, followed by incubation at 35°C for 24 h . Nares swab specimens were plated on mannitol salt agar; the methicillin resistance of S. aureus isolated in this manner was confirmed as previously described . Clinical data collected included demographic characteristics of the patients, initial location (i.e., long-term care facility, acute care facility, or home), underlying illness(es), and urinary tract catheterization status. Primary site of infection was classified on the basis of Centers for Disease Control and Prevention (CDC) definitions of nosocomial infection . A diagnosis of symptomatic urinary tract infection for the purposes of this study, however, required recovery of 105 bacteria/mL from a voided specimen or 104 bacteria/mL from a catheter specimen, no clinical evidence of a non–urinary tract site of infection, and at least 2 of the following symptoms: temperature of >38.5°C, change in mental status, gross hematuria, suprapubic discomfort, dysuria, or flank pain. We intentionally chose a strict definition requiring at least 2 symptoms, because fever alone has a low predictive value in localizing infection to the urinary tract in elderly patients with bacteriuria .
Nares and urine cultures were repeated every 2 months until culture results were negative for S. aureus for 2 consecutive samples or until the patient was lost to follow-up. Other samples were obtained for culture at the discretion of the patients’ primary care physicians. Patients were observed for the development of invasive staphylococcal infection for the duration of the follow-up period. Late-onset staphylococcal infection was defined as that which occurred ⩾ 7 days after the initial positive urine culture result. Antistaphylococcal therapy was defined as vancomycin administered to a patient with methicillin-resistant S. aureus (MRSA) bacteriuria and as either vancomycin or a β -lactam antibiotic administered to a patient with methicillin-susceptible staphylococcal bacteriuria.
Isolates of S. aureus were characterized by macrorestriction analysis of SmaI-digested genomic DNA by PFGE. Agarose plugs of bacterial DNA were digested overnight with 20 U of SmaI (New England Biolabs). PFGE was performed using the CHEF-DR-II System (Bio-Rad). The DNA was electrophoresed for 23 h at 14°C in a 1% agarose gel at 6 V/cm with a switch time of 5–40 s. Gels were stained with ethidium bromide and photographed under UV illumination . Strains were classified as identical (0 different bands), closely related (⩽ 3 different bands), possibly related (4–6 different bands), or unrelated (⩾ 7 different bands).
Patient data were stripped of identifiers and entered into a computer database. Contingency tables were analyzed using the 2-tailed χ 2 test or Fisher’ exact test. The study was deemed to be exempt from review by the local institutional review board.
We identified and entered into the study 102 consecutive patients for whom at least 1 urine culture was positive for S. aureus;table 1 presents the patients’ characteristics. Eighty-six percent of initial staphylococcal isolates were MRSA. All patients were male, reflecting the Veterans Affairs patient population, with a mean age of 72.8 years. Seventy percent were residents of a long-term care facility, 82% had a urinary catheter of some type in place, and 7% had a recent history of an invasive urinary tract procedure. Only 11% were continent of urine and free of a urinary device. Table 2 shows the clinical findings at the time of the initial positive urine culture result. Thirty-three percent of patients had a symptomatic urinary tract infection, as determined on the basis of study criteria at the time of initial isolation of S. aureus from the urine. Forty-eight percent of patients had a diagnosis of urinary tract infection made by a physician. Table 3 shows the frequency of symptoms among those patients with a diagnosis of urinary tract infection based on study criteria. Sixteen (48%) of 33 patients had at least 1 new symptom (hematuria, dysuria, suprapubic pain, or flank pain) specific to the urinary tract; 26 (79%) of 33 had pyuria.
Characteristics of 102 patients at the time of their first urine culture positive for Staphylococcus aureus.
Characteristics of 102 patients at the time of their first urine culture positive for Staphylococcus aureus.
Symptoms at presentation among 33 patients with urinary tract infection, according to the study definition.
Symptoms at presentation among 33 patients with urinary tract infection, according to the study definition.
Risk factors for bacteremia at time of the initial urine culture positive for Staphylococcus aureus.
Risk factors for bacteremia at time of the initial urine culture positive for Staphylococcus aureus.
Thirteen patients had S. aureus bacteremia identified in association with the first positive urine culture result. Three patients had positive blood culture results before (1–2 days before) urine samples were obtained for culture, 6 had positive blood culture and urine culture results on the same day, and 4 had positive blood culture results subsequent to (1–4 days following) the positive urine culture result. Only 2 patients had received antimicrobial agents ⩽ 14 days after onset of bacteremia. Table 2 presents the characteristics of patients with and patients without bacteremia. Ten (77%) of 13 patients had a bladder catheter present at the onset of bacteremia. Bacteremic patients were significantly more likely to have hematuria, but this occurred in only one-third of bacteremic patients. Patients with MRSA bacteriuria were not significantly more likely to be bacteremic than were those infected with methicillin-susceptible isolates. Initial nares cultures were performed for 76 patients, 57 (75%) of whom had nasal staphylococcal colonization.
Sixteen patients had late-onset staphylococcal infections— that is, infections that occurred after the initial positive urine culture result (range, 7 days to 12 months). Eight patients presented with late-onset S. aureus bacteremia that occurred 1–12 months after the initial urine culture. The primary foci of bacteremic infection were the urinary tract in 5 patients; blood and urine samples were obtained for culture on the same day for all 5. Patients with nonbacteremic infections included 5 patients with urinary tract infection. of the 10 patients with urinary tract infection (including the 5 with bacteremia), 7 had pyuria, and 4 had at least 1 new symptom specific to the urinary tract. All 5 patients with bacteremia had urine and blood samples obtained for culture on the same day.
Thirteen patients died within 30 days after the initial urine culture. of the survivors, 52% had ⩾ 2 additional cultures performed, 26% had a single additional culture performed, and 19% were discharged or otherwise lost to follow-up and had no additional cultures performed. of the 71 patients with at least 1 additional urine culture, 41 (58%) had at least 1 culture positive for S. aureus. The mean duration of colonization with S. aureus was 4.3 months. Patients with persistent urinary S. aureus colonization were more likely to have subsequent infection than those whose urine was free from S. aureus (34.6% vs. 10.5%; P =.086). Twenty-seven patients had at least 1 follow-up urine culture performed after they received antistaphylococcal antibiotic therapy. of these, 20 (84%) had cultures that were negative for S. aureus.
PFGE typing was performed for the initial urine isolates, as well as for the subsequent blood isolates, from 7 of the 8 patients with late-onset bacteremia. of these, 5 blood isolates matched the urine isolate, with 3 blood/urine isolate pairs being identical and 2 differing by only 1 band. Three blood isolates were different from the initial urine isolate.
S. aureus is a relatively infrequent urinary tract isolate in the general population. In a multicenter, community-based study conducted in Great Britain, S. aureus accounted for only 0.5% of isolates . A similar laboratory-based study conducted in France found that S. aureus accounted for only 1.3% of isolates from urine specimens submitted from the community . Prior studies suggest that isolation of S. aureus from the urine is often secondary to staphylococcal bacteremia originating at another site (e.g., in cases of endocarditis) . Isolation of S. aureus from urine samples in the absence of bacteremia is therefore often considered to represent colonization.
In specific patient populations, however, S. aureus can be an important primary urinary pathogen. For example, MRSA urinary tract infection occurs in both an endemic and epidemic fashion among patients undergoing urologic surgical procedures . MRSA bacteriuria occurs among long-term care patients as well, and it is significantly associated with urinary catheterization and antibiotic use . It is problematic to define the exact role of S. aureus as a cause of symptomatic urinary tract infection, as opposed to colonization, in this population. Long-term care patients have a high frequency of asymptomatic bacteriuria . There is evidence to suggest that the majority of febrile episodes in long-term care patients with bacteriuria are not, in fact, due to urinary tract infection . Furthermore, long-term care patients may have atypical symptoms in response to true infection . Thus, a significant problem with interpreting prior studies lies in the inherent difficulty in making a definitive diagnosis of urinary tract infection in the long-term care population.
For example, Capitano et al. identified 90 S. aureus infections during a retrospective cohort study in a single nursing home. of these, 48% were classified as urinary tract infection using a definition of fever (temperature, >37.5°C) in association with staphylococcal bacteriuria. As noted above, this definition of urinary tract infection has poor specificity in the long-term care population. In an observational cohort study, Pacio et al. reported that 13% of long-term care patients colonized with MRSA at any site developed symptomatic urinary tract infection. No definition of urinary tract infection was given, and molecular typing to confirm identity of the initial colonizing and subsequent infecting strains was not performed.
There is evidence that S. aureus is a primary urinary tract pathogen in this population. Using the CDC criteria for nosocomial infection to define urinary tract infection, we found that 4% of cases of bacteremia of urinary tract origin among long-term care patients were due to S. aureus . In a subsequent study of hospitalized nursing home patients, Mylotte et al. reported that 11% of bacteremic episodes with urinary tract infection as the putative source were cause by MRSA, as determined on the basis of symptoms and concomitant isolation of MRSA from urine samples. The specific urinary tract symptoms supporting a diagnosis of urinary tract infection were not given.
In our prospective study of 102 patients with S. aureus bacteriuria, we used an a priori definition of urinary tract infection that required the presence of at least 2 clinical indicators of infection. We intentionally used a more restrictive definition of infection than that used in reporting nosocomial infection because of the difficulty in differentiating asymptomatic bacteriuria from urinary tract infection in elderly persons and in persons with indwelling catheters in place. Even with a highly restrictive definition, we found that one-third of patients (33 of 102) with S. aureus bacteriuria had evidence of primary urinary tract infection, and one-third (13 of 33) of these patients were bacteremic at presentation. Furthermore, we found that, of the patients who had persistent staphylococcal bacteriuria, 14 (34%) of 41 had subsequent staphylococcal infection. of these, 12 had cases that were classified as urinary tract infection on the basis of our a priori definition. Six late-onset infections (43%) in these patients were associated with bacteremia. PFGE typing of the initial isolates and subsequent isolates associated with infection showed that the initial and subsequent isolates were identical or closely related in 5 of 7 patients whose isolates were typed. Thus, we document that, in the long-term care population, a urinary tract that is persistently colonized with S. aureus can be an important focus for the subsequent occurrence of staphylococcal infection. This risk appears to be greater than the risk associated with nares colonization alone. In a previous study from the same health care center, we noted that the incidence of infection associated with persistent MRSA nares colonization was 25% .
These findings have important implications for patient care. Because urinary catheterization is a major risk factor for S. aureus bacteriuria, reducing the prevalence of catheterization should be beneficial. Efforts to limit the acquisition of MRSA by catheterized patients through appropriate infection-control measures and limitation of unnecessary antibiotic administration are warranted in long-term care facilities.
Given the high risk of subsequent infection in patients whose urine is persistently colonized with S. aureus, it is appropriate to question whether elimination of MRSA colonization in these patients may be beneficial. In a general population of long-term care patients with MRSA colonization of the nares, application of mupirocin to the nares has not been shown to significantly reduce the risk of MRSA infection . It is unlikely that intranasal mupirocin would have any effect on urinary colonization in any event. Systemic therapy with antimicrobial agents that are excreted in the urine is a possible approach, but the results of the limited clinical trials involving this patient population have been disappointing. For example, the combination of rifampin and minocycline had a high failure rate with regard to eradicating MRSA in long-term care patients; resistance to both rifampin and minocycline occurred .
Our study has some potential limitations. The first is that the initial identification of staphylococcal bacteriuria required that a urine sample be obtained by a clinician’ order. Thus, the patient population identified may have differed from that identified by systematic surveillance of all patients for S. aureus in the urine. The second is that concomitant blood cultures were not performed for all patients with staphylococcal bacteriuria; some cases of bacteremia may have been missed. We note that this would cause underestimation of the importance of the urinary tract as the source for S. aureus bacteremia.
In summary, our study demonstrates that S. aureus— and MRSA in particular— is a primary urinary pathogen among long-term care patients. One-third of patients with MRSA bacteriuria have symptomatic urinary tract infection at presentation, and one-third of these patients have concomitant bacteremia. Persistent urinary colonization carries with it a high risk of subsequent infection and bacteremia. In patients who present with fever or sepsis, previous identification of S. aureus colonization of the urinary tract may be useful in selecting empirical antimicrobial therapy. This study demonstrates that focusing on the urine as a potential reservoir for infection may be an effective strategy for prevention.
We thank Larry M. Baddour, Kent Crossley, and Daniel M. Musher, for their valuable reviews of the manuscript.
Potential conflicts of interest. All authors: no conflicts.
1 Demuth PJ , Gerding GN , Crossley K . Staphylococcus aureus bacteriuria, Arch Intern Med, 1979, vol. 139 (pg. 78-80) 2 Barrett SP , Savage MA , Rebec MP , Guyot A , Andrews N , Shrimpton SB . Antibiotic sensitivity of bacteria associated with community-acquired urinary tract infection in Britain, J Antimicrob Chemother, 1999, vol. 44 (pg. 359-65) 3 Lee BK , Crossley K , Gerding DN . The association between Staphylococcus aureus bacteremia and bacteriuria, Am J Med, 1978, vol. 65 (pg. 303-6) 4 Coll PP , Crabtree BF , O’Connor PJ , Klenzak S . Clinical risk factors for methicillin-resistant Staphylococcus aureus bacteriuria in a skilled-care nursing home, Arch Fam Med, 1994, vol. 3 (pg. 357-60) 5 Breitenbucher RB . Bacterial changes in urinary samples of patients with long-term indwelling catheters, Arch Intern Med, 1984, vol. 144 (pg. 1585-8) 6 Warren JW , Damron D , Tenney JH , Hoopes JM , Deforge B , Muncie HL . Fever, bacteremia, and death as complications of bacteriuria in women with long-term urethral catheters, J Infect Dis, 1987, vol. 155 (pg. 1151-8) 7 Nicolle LE , Muir P , Harding GKM , Norris M . Localization of urinary tract infection in elderly, institutionalized women with asymptomatic bacteriuria, J Infect Dis, 1988, vol. 157 (pg. 65-70) 8 Orr PH , Nicolle LE , Duckworth H , et al. Febrile urinary infection in the institutionalized elderly, Am J Med, 1996, vol. 100 (pg. 71-7) 9 Nicolle LE . Urinary tract infection in long-term-care facility residents, Clin Infect Dis, 2000, vol. 31 (pg. 757-61) 10 Muder RR , Brennen C , Wagener MM , Goetz AM . Bacteremia in a long-term-care facility: a five-year prospective study of 163 consecutive episodes, Clin Infect Dis, 1992, vol. 14 (pg. 647-54) 11 Arpi M , Rennenberg J . The clinical significance of Staphylococcus aureus bacteriuria, J Urol, 1984, vol. 132 (pg. 697-700) 12 Mylotte JM , Tayara A , Goodnough S . Epidemiology of bloodstream infection in nursing home residents: evaluation in a large cohort from multiple homes, Clin Infect Dis, 2002, vol. 35 (pg. 1484-90) 13 Thornsberry C , McDougal LK . Successful use of broth microdilution in susceptibility tests for methicillin-resistant (heteroresistant) staphylococci, J Clin Microbiol, 1983, vol. 18 (pg. 1084-91) 14 Garner JS , Jarvis WR , Emori TG , Horan TC , Hughes JM . CDC definitions for nosocomial infections, 1988, Am J Infect Control, 1988, vol. 16 (pg. 128-40) 15 Tenover FC , Arbeit RD , Goering RV , et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing, J Clin Microbiol, 1995, vol. 33 (pg. 2233-9) 16 Goldstein FW . Antibiotic susceptibility of bacterial strains isolated from patients with community-acquired urinary tract infections in France, Eur J Clin Microbiol Infect Dis, 2000, vol. 19 (pg. 112-7) 17 Musher DM , McKenzie SO . Infections due to Staphylococcus aureus , Medicine, 1977, vol. 56 (pg. 383-409) 18 Araki M , Kariyama R , Monden K , Tsugawa M , Kumon H . Molecular epidemiological studies of Staphylococcus aureus in urinary tract infection, J Infect Chemother, 2002, vol. 8 (pg. 168-74) 19 Jones JW , Carter A , Ewings P , O’Boyle PJ . An MRSA outbreak in a urolgy ward and its association with Nd:YAG coagulation laser treatment of the prostate, J Hosp Infect, 1999, vol. 41 (pg. 39-44) 20 Bentley DW , Bradley S , High K , Schoenbaum S , Taler G , Yoshikawa TT . Practice guideline for evaluation of fever and infection in long-term care facilities, J Am Geriatr Soc, 2001, vol. 49 (pg. 210-22) 21 Capitano B , Leshem OA , Nightingale CH , Nicolau DP . Cost effect of managing methicillin-resistant Staphylococcus aureus in a long-term care facility, J Am Geriatr Soc, 2003, vol. 51 (pg. 10-6) 22 Pacio GA , Visintainer P , Maguire G , Wormser GP , Raffalli J , Montecalvo MA . Natural history of colonization with vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and resistant gram-negative bacilli among ling-term-care facility residents, Infect Control Hosp Epidemiol, 2003, vol. 24 (pg. 246-50) 23 Muder RR , Brennen C , Wagener MM , et al. Methicillin resistant staphylococcal colonization and infection in a long-term care facility, Ann Intern Med, 1991, vol. 114 (pg. 107-12) 24 Mody L , Kauffman CA , McNeil SA , Galecki AT , Bradley SF . Mupirocin-based decolonization of Staphylococcus aureus carriers in residents of 2 long-term care facilities: a randomized, double-blind, placebo-controlled trial, Clin Infect Dis, 2003, vol. 37 (pg. 1467-74) 25 Muder RR , Boldin M , Brennen C , et al. A controlled trial of rifampicin, minocycline, and rifampicin plus minocycline for eradication of methicillin-resistant Staphylococcus aureus in long-term care patients, J Antimicrob Chemother, 1994, vol. 34 (pg. 189-90) © 2005 by the Infectious Diseases Society of America
MRSA in the Bladder
Hip dysplasia usually appears very early in life, though in some cases it can develop over time. As children get older, doctors can no longer perform the maneuvers that they use during the newborn period to check hips. In your older daughter, you would look to make sure that both legs are the same length; that the creases on the legs look symmetric; that her gait, or quality of movement, is normal; and that she has full range of motion and strength that are equal in both legs. If all of these things appear to be normal, it is very unlikely that your six year old has DDH.
Q4. There has been a confirmed case of MRSA in our school, and my 7-year-old’s immune system is not that strong – what can I do to protect him from this infection?
You are not alone with this concern! Many people are worried about MRSA (methicillin-resistant Staphylococcus aureus). MRSA is a type of staph bacterium that must be treated with different antibiotics from those used to treat the more usual staph bacterium. MRSA that exists in the community, however, is different from MRSA that occurs in a hospital, and it can usually be treated with several antibiotics taken by mouth.
MRSA has actually been all around us for years. In fact, up to 40 percent of people carry some type of staph in their noses. There is no reason to treat your son in advance, though if he were to get a skin infection, it would be a good idea to alert his pediatrician about his exposure to MRSA. Treating him without knowing he is infected just increases the chance that the staph bacteria would become resistant to even more antibiotics!
Staph is the most common cause of skin infections, so there are some easy hygiene steps you can take to help prevent the spread of infection. Advise your child not to share items such as washcloths, bedding, sports jerseys, helmets, and other equipment — all of which can transmit infection from a child who has a skin infection. Wash clothing and bedding and dry with high heat to help kill bacteria. Cover cuts and skin infections with Band-Aids to prevent the spread of bacteria. As always, careful hand washing is the best prevention against most infections, including MRSA.
Learn more in the Everyday Health Healthy Living Center.
All you need to know about MRSA
MRSA results from infection with bacterial strains that have acquired resistance to particular antibiotics.
MRSA is contagious
MRSA can spread from person to person through direct skin-to-skin contact or when a person with MRSA bacteria on their hands touches an object that another person then touches.
MRSA bacteria can survive for a long time on surfaces and objects, including fabrics and door handles.
In 2000, scientists investigated how long resistant staph could survive on five common hospital fabrics. They injected the fabrics with colony-forming units of staph and observed the reactions over the following days.
They found that the bacteria could survive for:
- 4–21 days on 100% smooth cotton (clothing)
- 2–14 days on 100% cotton terry (towels and washcloths)
- 1–3 days on a 60% cotton, 40% polyester blend (scrub suits, lab coats, and clothing)
- 1–40 days on 100% polyester (privacy drapes, curtains, and clothing)
- 40 to longer than 51 days on 100% polypropylene plastic (splash aprons)
These results demonstrate the need for thorough contact control and meticulous disinfection procedures to limit the spread of bacteria.
MRSA frequently causes illness in people with a compromised immune system who spend time in the hospital and other healthcare facilities.
This type is called healthcare-associated MRSA or hospital-acquired MRSA.
MRSA is more likely to happen in a hospital because:
- Infections can easily spread when there are many people in a limited space.
- People in the hospital may have a higher risk of contracting the infection.
- When people are older or have certain health conditions, they may be less able to resist infection.
A person will have a higher risk of developing healthcare-associated MRSA in the hospital if they have had surgery recently or if they have:
- a weakened immune system
- an open wound
- a catheter or intravenous drip
- burns or cuts to the skin surface
- a severe skin condition
- frequent antibiotics as part of their treatment
A person may have a weakened immune system if they:
- have been a patient in a hospital for a long time
- have had an organ transplant
- are undergoing kidney dialysis
- are receiving cancer treatment or have certain types of cancer
- are using medications that affect immune function
- inject recreational drugs
- have had surgery within a year of previous hospitalization
MRSA is less common outside a healthcare setting. If it does occur, it is more likely to be a skin infection, although some people develop pneumonia and other infections.
Factors that increase the risk of developing community-associated MRSA include:
- living with a lot of people, such as on a military base, in jail, or on a campus
- having regular skin-to-skin interaction with other people, for example, in contact or collision sports, such as soccer
- doing a job or hobby that increases the risk of cuts or grazes to the skin
- regularly injecting drugs
- having low adherence to personal or environmental hygiene
- previous antibiotic use
People can reduce the risk by practicing appropriate hand washing, keeping wounds clean, avoiding sharing personal items — such as towels and razors, and seeking early treatment if any symptoms of an infection appear.
Children can develop MRSA through an open wound. Find out how to recognize it and what to do.
Copyright: © 2015 Ranganathan Vasudevan. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
MRSA UTI Prevention – 5 Contributing Factors to Developing a MRSA UTI in a Nursing Home
Methicillin Resistant Staphylococcus Aureus (MRSA) UTIs are increasing throughout the United States, and transmissions acquired in hospitals and care facilities are of particular concern. A MRSA UTI cannot be treated with traditional antibiotics and the prevalence of antibiotic resistant bacteria is a growing problem, especially for the elderly living in residential care facilities, as more strains of bacteria adapt to commonly used antibiotics.
Elderly residents are likely to have taken antibiotics over the years, allowing for the development of some resistant bacteria, and the combination of debilitated patients with compromised immune systems, and a certain level of antibiotic resistance places them at greater risk of MRSA infections.
Several specific factors contribute to the likelihood of contracting a MRSA urinary tract infection (UTI) in a nursing home or other long-term care facility.
MRSA UTI Risk Factor #1: Exposure to Carriers
Studies have shown that residents in long-term care facilities are more likely to be carriers of MRSA in general. It is believed that patients often contract MRSA during a stay at a hospital or acute care facility, rather than in a nursing home or long term care residence, however, facilities where many people are living in close proximity to one another can be prime areas of contagion. While infection control protocols are in place in most facilities, research has indicated that none are substantially effective in reducing the spread of infections, partially due to the highly contagious nature of MRSA and also to the fact that it may be unreasonable to attempt to limit residents’ mobility and social interactions given that the facility is their home.
MRSA UTI Risk Factor #2: Invasive Medical Devices
Use of invasive devices like urinary catheters: Since MRSA, like other staph organisms, can live on the skin, hygiene is the first line of defense in controlling spread of infection. While healthy people can carry staph on their skin without being infected by it, elderly residents have a much harder time fighting off stubborn organisms like MRSA. Urinary tract infections are common in nursing homes and long-term care facilities. Many elderly patients have poor bladder control and depend on a urinary catheter which can provide bacteria a direct route into the body, particularly if the catheter is left in place for long periods of time without being replaced.
MRSA UTI Risk Factor #3: Impaired Cognitive Function
Increasing the amount of fluids in the person’s diet will help to flush out bacteria from the bladder and urinary tract, but elderly residents may not remember to drink enough without close monitoring. In addition to being incontinent, long-term care residents may be mobility-impaired and confused which contribute to the possibility of a UTI. Patients who do not have a catheter but still have issues with incontinence may refrain from drinking larger amounts of fluids in an attempt to avoid accidents, and this provides an opportunity for bacteria in the bladder and urinary tract to thrive.
MRSA UTI Risk Factor #4: Impaired Immune Function
If poor clinical status and chronic illnesses are the norm in residences for the elderly, endemic infections may not be preventable. Residents may have chronic medical conditions that decrease the effectiveness of their immune system, and this makes MRSA infections more dangerous and potentially even life-threatening. The inability of many elderly patients to communicate adequately with staff, combined with a high frequency of asymptomatic MRSA UTIs may create a nearly impossible situation. The use of high-power antibiotics that are effective on resistant bacteria like MRSA can be very hard on the patient in treatment, and may affect kidney function as well.
MRSA UTI Risk Factor #5: High Potential for Contagion
MRSA is highly a highly contagious organism that can be transmitted by direct contact with infected persons, towels, wash cloths, bedding, drinking glasses or any other items handled by infected residents, especially if cognitive changes are present that prevent patients from being fully aware of things like proper and frequent hand-washing. MRSA that may begin as a nasal or respiratory infection can easily be transferred to other parts of the body.
Learning about MRSA: A guide for Patients
- Download a print/booklet version of this document: Learning about MRSA: A guide for Patients (PDF)
- Download a factsheet version of this document: Learning about MRSA Fact Sheet: A guide for Patients (PDF)
On this page:
Preventing the Spread
Caring for Yourself
What is MRSA and why is it so serious?
- Staphylococci or “staph” bacteria commonly live on the skin and in the nose. Usually, staph bacteria don’t cause any harm.
- However,if they get inside the body they can cause an infection.
- When common antibiotics don’t kill the staph bacteria, it means the bacteria have become resistant to those antibiotics.
- This type of staph is called MRSA (Methicillin-Resistant Staphylococcus aureus).
- MRSA was first identified in the 1960’s and was mainly found in hospitals and nursing homes.
- In the late 1990’s, a new type of MRSA was identified.
- This type of MRSA is becoming more common among children and adults who do not have medical conditions.
What does MRSA look like?
Most often, MRSA causes infections on the skin. These infections may look like any one of the following:
- Large, red, painful bumps under the skin (called boils or abscesses)
- A cut that is swollen, hot and filled with pus
- Blisters filled with pus (called impetigo)
- Sores that look and feel like spider bites (However, MRSA is not caused by a spider bite or any other insect bite.)
It is also possible to have MRSA in other areas of the body, such as blood, lungs, joints, eyes, and urine. These types of infections are less common, although they can be more serious. Because skin infections are the most common, this booklet will focus on them.
How did I get MRSA?
- Anyone can get MRSA. You can get MRSA by touching someone or something that has the bacteria on it and then touching your skin or your nose.
Some ways that you could get MRSA:
- Touching the infected skin of someone who has MRSA
- Using personal items of someone who has MRSA, such as towels, wash cloths, clothes or athletic equipment
- Touching objects, such as public phones or door knobs, that have MRSA bacteria on the surface and then touching your nose or an open sore, paper cut, etc.
You may increase your chances of getting MRSA if:
- You take antibiotics a lot
- You take antibiotics without a prescription
- You don’t follow your doctor’s directions when taking antibiotics (for example you stop taking your antibiotics before finishing a prescription or you skip doses)
- You frequently get cuts or scrapes on your skin (Your skin serves as a barrier to infection. When the skin gets damaged staph bacteria can enter and increase your risk for infection.)
There are two ways you can have MRSA.
- You can have an active infection. An active infection means you have symptoms. This is usually a boil, a sore, or an infected cut that is red, swollen, or pus-filled.
- You can be a carrier. If you are a carrier you do not have symptoms that you can see, but you still have MRSA bacteria living in your nose or on your skin. If you are a carrier, your doctor may say that you are colonized. These words – “carrier” and “colonized” – mean the same thing.
Will I always have MRSA?
- Many people with active infections are treated effectively, and no longer have MRSA.
- However, sometimes MRSA goes away after treatment and comes back several times.
- If MRSA infections keep coming back again and again, your doctor can help you figure out the reasons you keep getting them.
If I have MRSA, do I need to do anything special when I go to a clinic or hospital?
- If you have ever had an active MRSA infection or you are a carrier, you should tell your health care providers.
- They will wash their hands and wear gloves when caring for you.
- They may also wear a gown over their clothes and may wear a mask.
- If you are staying in a hospital or nursing home, a “Special Precautions” card may be put on the door of your room.
- This card alerts staff to use extra care to prevent the spread of MRSA.
- Your visitors may be instructed to avoid touching infected skin and to take other precautions such as wearing gloves or gowns when visiting you.
Is there a test for MRSA?
- You would not usually be tested for MRSA unless you have an active infection. If you have a skin infection, your doctor may take a sample of the area to find out what bacteria is causing your infection. This is called taking a culture. The lab will then test the bacteria to find out which antibiotic is best for you. If your MRSA infections keep coming back again and again, your doctor may test you and your family members to see if you are carriers. In this case, the doctor would take a culture from the nose or other areas where MRSA can be found.
How is MRSA treated?
- MRSA should always be treated by a doctor. It is important to follow the instructions for treatment that your doctor gives you.
If you have an active MRSA infection, your doctor may choose one or more of the following treatments:
- Give antibiotics
- Drain the infection
- Reduce the amount of staph on your skin and in your nose
1. Give antibiotics
MRSA is resistant to many antibiotics so it can be difficult to treat. However, there are antibiotics that can treat MRSA and make the infection go away. Your doctor may culture your infection and have the lab test the bacteria to find out which antibiotic is best for you. If your doctor gives you antibiotics, take them exactly as prescribed. Do not stop early, even if you feel better or if your infection looks healed. The last few pills kill the toughest germs. Never take antibiotics without a prescription from your doctor.
2. Drain the infection
Don’t do this yourself. It is very dangerous to squeeze or poke a skin infection because it can push the bacteria deeper into the skin and make the infection much worse. Your doctor will open the sore and drain it. After the infection is drained, you must keep it covered with a clean, dry bandage, until it heals
3. Reduce the amount of staph on your skin or in your nose
This may prevent the spread of MRSA if you have an active infection or if you are a carrier.
To decrease the amount of staph on your body your doctor may, for a short period of time:
- Tell you to shower daily with antibacterial soap
- Prescribe antibiotic ointment to put in your nose for several days
- Prescribe antibiotic pills (in some cases)
Contact your doctor if:
- you have any new symptoms during or after treatment for a MRSA skin infection such as a new fever or a fever that won’t go away
- the infection gets worse
- the infection is not healing
- the infection comes back
- you have questions
Preventing the Spread of MRSA
What can I do to prevent spreading my infection to others?
- Clean your hands often with soap and water or an alcohol-based hand sanitizer
- Take a bath or shower often, be sure to use soap to clean your body while showering or bathing
- Wash your sheets and towels at least once a week
- Change your clothes daily and wash them before wearing again
- Do not share towels, wash cloths, razors, or other personal items
- If you get a cut or scrape on your skin, clean it with soap and water and then cover it with a bandage
- Do not touch sores; if you do touch a sore, clean your hands right away
- Cover any infected sores with a bandage and clean your hands right away after putting on the bandage
- Wear clothes that cover your bandages and sores, if possible
- Clean frequently used areas of your home (bathrooms, countertops, etc.) daily with a household cleaner
- Do not participate in contact sports until your sores have healed
- Do not go to a public gym, sauna, hot tub or pool until sores have healed
Caring for Yourself
Does it matter how I wash my hands?
- Yes. You have to rub your hands for at least 20 seconds to get rid of the bacteria.
How do I clean my hands with alcohol-based hand sanitizer?
- Use enough to cover all the surfaces of your hands.
Clean Your Hands! Poster
This 11×17 poster shows the six steps for washing hands with soap and water or two for cleaning with alcohol-based hand sanitizers.
Do I need to be careful when I do laundry?
Yes. Dirty clothes and bedding can spread MRSA bacteria.
- When touching your laundry or changing your sheets, hold the dirty laundry away from your body and clothes to prevent bacteria from getting on your clothes
- Wear disposable gloves to touch laundry that is soiled with body fluids, like drainage from a sore, urine or feces
- Immediately put the laundry into the washer or into a plastic bag until it can be washed
- Wash your laundry with warm or hot water, use bleach if possible
- Dry in a warm or hot dryer and make sure the clothes are completely dry
- Clean your hands after touching dirty sheets or clothing and before touching clean laundry, even if you have been wearing gloves
- Throw gloves away after taking them off (do not reuse them) and clean your hands
How often should I change clothes and bedding?
- Change your sheets and towels at least once a week
- Change your clothes daily
- Do not put dirty clothes or clothes you have just worn back in your closet or drawers until they have been washed
What about cleaning my house?
- Use a household disinfectant or bleach solution to clean surfaces daily
- Pay attention to items that are frequently touched – light switches, doorknobs, phones, toilets, sinks, tubs and showers and kitchen counters
- Wipe the surface or object with the disinfectant and let it dry
Disinfectants to use:
- You can use any cleaner you buy at the grocery store that has the word “disinfectant” on it, remember to read the label and follow the directions
- Make your own solution of bleach and water:
- Mix two teaspoons bleach into one quart of water in a spray bottle and label it “bleach solution”
- Make it fresh each time you plan to clean because the bleach evaporates out of the water making it less effective
- Never mix bleach with other cleaners, especially ammonia
- Keep the bleach solution away from children and don’t put it in bottles that could be mistaken for something to drink
How often should I clean?
- It is important that you clean daily. Especially items or surfaces you touch often.
- Changing Bandages
Poster showing the steps for how to change your bandages.
- MRSA can cause serious infections that can become life-threatening if left untreated.
- If you or someone in your family has been diagnosed with MRSA, there are steps you should take to avoid spreading it to your family and friends.
- Follow the recommendations and practice good hygiene to take care of yourself.
- MRSA may cause physical pain and emotional stress, but keep in mind that it can be managed.
Things to remember about having MRSA:
- Clean your hands often
- Take care of yourself: eat right, exercise, quit smoking, and avoid stress
- Take good care of your skin
- Keep skin infections covered to avoid spreading MRSA to others
- Talk with your doctor if you have questions or concerns