About two years ago, the death of a high school student athlete brought methicillin-resistant Staphylococcus aureus (MRSA) into the national spotlight. Preventing the spread of MRSA in schools, gyms, and other public facilities is an important public health goal. This Issue Brief presents current information on the prevalence and transmission of MRSA in community settings, and describes ongoing research on interventions to limit the spread of this increasingly common infection

Lautenbach, Ebbing

Zaoutis, Theoklis

English

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics8-24-2009Preventing MRSA Infection in the CommunityEbbing LautenbachUniversity of PennsylvaniaTheoklis ZaoutisUniversity of PennsylvaniaFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsPart of the Community Health and Preventive Medicine Commons, Health Services ResearchCommons, and the Public Health Education and Promotion CommonsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/82For more information, please contact repository@pobox.upenn.edu.Lautenbach, Ebbing and Zaoutis, Theoklis. Preventing MRSA Infection in the Community. LDI Issue Briefs. 2009; 14 (6).http://ldi.upenn.edu/policy/issue-briefs/2009/08/24/untitled-64Preventing MRSA Infection in the CommunityAbstractAbout two years ago, the death of a high school student athlete brought methicillin-resistant Staphylococcusaureus (MRSA) into the national spotlight. Preventing the spread of MRSA in schools, gyms, and otherpublic facilities is an important public health goal. This Issue Brief presents current information on theprevalence and transmission of MRSA in community settings, and describes ongoing research oninterventions to limit the spread of this increasingly common infection.Keywordshealth behavior & communication, disease prevention/health promotionDisciplinesCommunity Health and Preventive Medicine | Health Services Research | Public Health Education andPromotionLicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/82Issue BriefLDILeonard Davis Institute of Health Economics Volume 14, Number 6 • August 2009MRSA is not new, but isappearing morefrequently in communitysettingsEbbing Lautenbach, MD, MPH,MSCELDI Senior Fellow, Associate Professorof Medicine and EpidemiologyCenter for Education and Researchon TherapeuticsUniversity of PennsylvaniaTheoklis Zaoutis, MD, MSCEAssociate Professor of Pediatrics andEpidemiologyThe Children’s Hospital ofPhiladelphiaCenter for Education and Researchon TherapeuticsUniversity of PennsylvaniaContinued on next page.Preventing MRSA Infection in theCommunityEditor’s note:  About two years ago, the death of a high school student athletebrought methicillin-resistant Staphylococcus aureus (MRSA) into the nationalspotlight. Preventing the spread of MRSA in schools, gyms, and other publicfacilities is an important public health goal. This Issue Brief presents currentinformation on the prevalence and transmission of MRSA in communitysettings, and describes ongoing research on interventions to limit the spreadof this increasingly common infection.Methicillin-resistant Staphylococcus aureus (MRSA) emerged in health care settings inthe 1960s.  This strain of the common “staph” bacteria is resistant to manyantibiotics, and poses a threat to the health of patients in hospitals, nursing homes,dialysis centers, and ambulatory surgical centers. When compared to methicillin-susceptible S. aureus infections, infections due to MRSA have been associated withsignificantly increased morbidity, mortality, and cost. Historically, MRSA hasaffected vulnerable patients in health care settings. However, over the past few years,MRSA has emerged as a prominent cause of infections in otherwise healthy adultsand children in the community.• Community-acquired MRSA strains generally cause skin and soft tissueinfections, although occasionally they manifest in pneumonia or severe invasiveinfections.  There is some evidence the community strains of MRSA may be morevirulent that hospital MRSA strains. They require prompt treatment to avoidserious complications.• Many people are colonized with staph, meaning that they carry the bacteria in thenose or skin folds without showing signs of infection or illness. About 30% ofpeople are colonized with non-resistant staph, and about 1% are colonized withMRSA.  This prevalence varies by area of the country.MRSA infections aretreatable, but they canrecurHand hygiene preventsMRSA infection• Skin infections occur when the bacteria enters the body through a scrape or cut.The infected area usually begins with a red bump that resembles a pimple orinsect bite. If untreated, the lesion may become hard and painful or pus-filled.• MRSA is transmitted mostly through skin-to-skin contact, as well as throughsharing items such as towels and razors that have been in contact with the infectedarea.  The contagiousness of MRSA has created the need for preventive measuresin places where crowding and contact occur, such as schools, camps, gyms,barracks, and prisons.The best prevention against MRSA infection is also one of the oldest and surest waysto reduce the spread of many organisms: consistent attention to handwashing andgood hygiene.• Thorough handwashing with soap and water (or use of an alcohol-based handsanitizer) is the primary strategy to avoid MRSA infection.• Because cuts and scrapes are a portal for MRSA infection, it is important to keepcuts and scrapes clean and covered with a bandage until healed, and to avoidcontact with other people’s wounds or bandages.• Sharing personal items such as towels or razors, or anything that makes contactwith skin, should be avoided.• Showering or washing after contact sports or gym may reduce the risk of skin-to-skin transmission.• On shared surfaces such as gym or athletic equipment, using a barrier of clothingor towels reduces the risk of MRSA transmission.The vast majority of community-acquired MRSA skin infections are successfullytreated by incision and drainage of the lesion, sometimes in conjunction withantibiotic therapy. More invasive infections may require hospitalization.• Most MRSA infections are treated by good wound and skin care that includeskeeping the area clean and dry, washing hands after caring for the area, andcarefully disposing of any bandages.  If antibiotics are needed, the entire courseshould be taken to reduce the risk that the MRSA strain will become resistant tothe antibiotics that work today.• Individuals often remain colonized with MRSA after the symptoms have resolved.It is likely that prolonged colonization contributes to repeated episodes of MRSAinfection, and a greater likelihood of transmitting it to others.  The recurrencerate, though not well-documented, is believed to be 10-30%.• In the case of recurrent infections, one strategy is to “decolonize” the individualby using antibiotic nasal ointment and/or body washes.  The duration andeffectiveness of this strategy in preventing infections remain unknown.Continued on back.POLICY IMPLICATIONSInstitutional response toMRSA should target modeof transmission, not theindividualBecause MRSA is spread by skin-to-skin-contact or by sharing personal items,household members and others who have close personal contact (such as sportsteammates) are at risk of developing MRSA.• The rate of household transmission of MRSA is not known.  Small studies havefound that up to 70% of household contacts of a MRSA-infected individual arecolonized with MRSA, but most contacts do not develop an infection.  Theepidemiology of household transmission is not well understood.• Some evidence suggests that colonization of a household member is associatedwith a prolonged duration of MRSA infection in the affected individual.Interventions to decolonize household members have been tried, but need furtherstudy to determine whether they reduce transmission of MRSA infections withinfamilies or in the community.• To reduce the likelihood of household transmission, the same preventive strategiesof hand hygiene and not sharing personal items should be followed.  In addition,clothing that has come into contact with a draining wound should be launderedafter each use, and dried thoroughly.Schools and other community institutions at risk should have policies in place tocontain the spread of MRSA.• In general, it is not necessary to close a facility because of MRSA infections.Attention to hand hygiene, covering wounds until healed, and cleaning surfaceslikely to be in contact with wounds should limit the spread of MRSA.• Cleaning high-contact areas with detergent-based cleansers or EnvironmentalProtection Agency (EPA)-registered disinfectants is effective against MRSA.Surfaces such as floors and walls are not usually involved in the transmission ofMRSA.• There is no need to exclude an individual with a MRSA infection from allactivities, as long as draining wounds can be covered and hand hygiene isfollowed.• An affected individual should avoid whirlpools, swimming pools, and activities inwhich bandages might come off.The prevalence of MRSA is rising, although most people in the community are notat risk for a serious invasive infection. Still, the rise of community-acquired MRSArequires individual and institutional action to limit the spread of the bacteria and toavoid serious complications in both hospital and community settings.• The most effective way to prevent MRSA infection is through hand hygiene andwound covering. Institutions that are characterized by crowding and frequentskin-to-skin-contact (such as schools, college dorms, daycare centers, correctionalfacilities, military barracks, and gyms) should develop and maintain policies thatpromote consistent adherence to handwashing and hygiene guidelines.Household members oftencarry the MRSA bacteriaNonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue BriefPublished by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTEDThis Issue Brief was supported by the Agency for Healthcare Research and Quality, Centers for Education and Research on Therapeutics, Universityof Pennsylvania School of Medicine (U18 HS016946).  The opinions expressed are those of the authors and not the funding agency.Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104.Janet Weiner, MPH, Associate Director for Health Policy, EditorDavid A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, and social and ethicalissues that influence how health care is organized, financed, managed, and delivered in the United States and internationally. The LDI is a cooperativeventure among Penn schools including Medicine, Nursing, Dental Medicine, Communication, and Wharton, and the Children’s Hospital of Philadelphia.For additional information on this or other Issue Briefs, contact Janet Weiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).© 2009 Leonard Davis InstituteVisit us on the web at www.upenn.edu/ldiPOLICY IMPLICATIONSContinued• New strategies for preventing MRSA transmission in the community require animproved understanding of the dynamics of colonization and infection amongadults and children within households. A longitudinal study is ongoing at theUniversity of Pennsylvania to better understand how MRSA spreads withinhousehold members and the factors contributing to the spread of MRSA withinthe household.• The development of antibiotic-resistant organisms, in general, is linked to overuseand improper use of antibiotics. It is possible that prior antibiotic use is associatedwith the development of MRSA infection in an individual.  Ongoing research atthe University of Pennsylvania is investigating the link between antibiotic use andMRSA in children.  If this link is confirmed, it would add another compellingargument for the judicious use of antibiotics.

Preventing MRSA Infection in the Community

Kosmopolis

University of Pennsylvania
ScholarlyCommons
Issue Briefs Leonard Davis Institute of Health Economics
8-24-2009
Preventing MRSA Infection in the Community
Ebbing Lautenbach
University of Pennsylvania
Theoklis Zaoutis
University of Pennsylvania
Follow this and additional works at: http://repository.upenn.edu/ldi_issuebriefs
Part of the Community Health and Preventive Medicine Commons, Health Services Research
Commons, and the Public Health Education and Promotion Commons
This paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/82
For more information, please contact repository@pobox.upenn.edu.
Lautenbach, Ebbing and Zaoutis, Theoklis. Preventing MRSA Infection in the Community. LDI Issue Briefs. 2009; 14 (6).
http://ldi.upenn.edu/policy/issue-briefs/2009/08/24/untitled-64
Preventing MRSA Infection in the Community
Abstract
About two years ago, the death of a high school student athlete brought methicillin-resistant Staphylococcus
aureus (MRSA) into the national spotlight. Preventing the spread of MRSA in schools, gyms, and other
public facilities is an important public health goal. This Issue Brief presents current information on the
prevalence and transmission of MRSA in community settings, and describes ongoing research on
interventions to limit the spread of this increasingly common infection.
Keywords
health behavior & communication, disease prevention/health promotion
Disciplines
Community Health and Preventive Medicine | Health Services Research | Public Health Education and
Promotion
License
This work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.
This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/82
Issue BriefLD
I
Leonard Davis Institute of Health Economics Volume 14, Number 6 • August 2009
MRSA is not new, but is
appearing more
frequently in community
settings
Ebbing Lautenbach, MD, MPH,
MSCE
LDI Senior Fellow, Associate Professor
of Medicine and Epidemiology
Center for Education and Research
on Therapeutics
University of Pennsylvania
Theoklis Zaoutis, MD, MSCE
Associate Professor of Pediatrics and
Epidemiology
The Children’s Hospital of
Philadelphia
Center for Education and Research
on Therapeutics
University of Pennsylvania
Continued on next page.
Preventing MRSA Infection in the
Community
Editor’s note:  About two years ago, the death of a high school student athlete
brought methicillin-resistant Staphylococcus aureus (MRSA) into the national
spotlight. Preventing the spread of MRSA in schools, gyms, and other public
facilities is an important public health goal. This Issue Brief presents current
information on the prevalence and transmission of MRSA in community
settings, and describes ongoing research on interventions to limit the spread
of this increasingly common infection.
Methicillin-resistant Staphylococcus aureus (MRSA) emerged in health care settings in
the 1960s.  This strain of the common “staph” bacteria is resistant to many
antibiotics, and poses a threat to the health of patients in hospitals, nursing homes,
dialysis centers, and ambulatory surgical centers. When compared to methicillin-
susceptible S. aureus infections, infections due to MRSA have been associated with
significantly increased morbidity, mortality, and cost. Historically, MRSA has
affected vulnerable patients in health care settings. However, over the past few years,
MRSA has emerged as a prominent cause of infections in otherwise healthy adults
and children in the community.
• Community-acquired MRSA strains generally cause skin and soft tissue
infections, although occasionally they manifest in pneumonia or severe invasive
infections.  There is some evidence the community strains of MRSA may be more
virulent that hospital MRSA strains. They require prompt treatment to avoid
serious complications.
• Many people are colonized with staph, meaning that they carry the bacteria in the
nose or skin folds without showing signs of infection or illness. About 30% of
people are colonized with non-resistant staph, and about 1% are colonized with
MRSA.  This prevalence varies by area of the country.
MRSA infections are
treatable, but they can
recur
Hand hygiene prevents
MRSA infection
• Skin infections occur when the bacteria enters the body through a scrape or cut.
The infected area usually begins with a red bump that resembles a pimple or
insect bite. If untreated, the lesion may become hard and painful or pus-filled.
• MRSA is transmitted mostly through skin-to-skin contact, as well as through
sharing items such as towels and razors that have been in contact with the infected
area.  The contagiousness of MRSA has created the need for preventive measures
in places where crowding and contact occur, such as schools, camps, gyms,
barracks, and prisons.
The best prevention against MRSA infection is also one of the oldest and surest ways
to reduce the spread of many organisms: consistent attention to handwashing and
good hygiene.
• Thorough handwashing with soap and water (or use of an alcohol-based hand
sanitizer) is the primary strategy to avoid MRSA infection.
• Because cuts and scrapes are a portal for MRSA infection, it is important to keep
cuts and scrapes clean and covered with a bandage until healed, and to avoid
contact with other people’s wounds or bandages.
• Sharing personal items such as towels or razors, or anything that makes contact
with skin, should be avoided.
• Showering or washing after contact sports or gym may reduce the risk of skin-to-
skin transmission.
• On shared surfaces such as gym or athletic equipment, using a barrier of clothing
or towels reduces the risk of MRSA transmission.
The vast majority of community-acquired MRSA skin infections are successfully
treated by incision and drainage of the lesion, sometimes in conjunction with
antibiotic therapy. More invasive infections may require hospitalization.
• Most MRSA infections are treated by good wound and skin care that includes
keeping the area clean and dry, washing hands after caring for the area, and
carefully disposing of any bandages.  If antibiotics are needed, the entire course
should be taken to reduce the risk that the MRSA strain will become resistant to
the antibiotics that work today.
• Individuals often remain colonized with MRSA after the symptoms have resolved.
It is likely that prolonged colonization contributes to repeated episodes of MRSA
infection, and a greater likelihood of transmitting it to others.  The recurrence
rate, though not well-documented, is believed to be 10-30%.
• In the case of recurrent infections, one strategy is to “decolonize” the individual
by using antibiotic nasal ointment and/or body washes.  The duration and
effectiveness of this strategy in preventing infections remain unknown.
Continued on back.
POLICY IMPLICATIONS
Institutional response to
MRSA should target mode
of transmission, not the
individual
Because MRSA is spread by skin-to-skin-contact or by sharing personal items,
household members and others who have close personal contact (such as sports
teammates) are at risk of developing MRSA.
• The rate of household transmission of MRSA is not known.  Small studies have
found that up to 70% of household contacts of a MRSA-infected individual are
colonized with MRSA, but most contacts do not develop an infection.  The
epidemiology of household transmission is not well understood.
• Some evidence suggests that colonization of a household member is associated
with a prolonged duration of MRSA infection in the affected individual.
Interventions to decolonize household members have been tried, but need further
study to determine whether they reduce transmission of MRSA infections within
families or in the community.
• To reduce the likelihood of household transmission, the same preventive strategies
of hand hygiene and not sharing personal items should be followed.  In addition,
clothing that has come into contact with a draining wound should be laundered
after each use, and dried thoroughly.
Schools and other community institutions at risk should have policies in place to
contain the spread of MRSA.
• In general, it is not necessary to close a facility because of MRSA infections.
Attention to hand hygiene, covering wounds until healed, and cleaning surfaces
likely to be in contact with wounds should limit the spread of MRSA.
• Cleaning high-contact areas with detergent-based cleansers or Environmental
Protection Agency (EPA)-registered disinfectants is effective against MRSA.
Surfaces such as floors and walls are not usually involved in the transmission of
MRSA.
• There is no need to exclude an individual with a MRSA infection from all
activities, as long as draining wounds can be covered and hand hygiene is
followed.
• An affected individual should avoid whirlpools, swimming pools, and activities in
which bandages might come off.
The prevalence of MRSA is rising, although most people in the community are not
at risk for a serious invasive infection. Still, the rise of community-acquired MRSA
requires individual and institutional action to limit the spread of the bacteria and to
avoid serious complications in both hospital and community settings.
• The most effective way to prevent MRSA infection is through hand hygiene and
wound covering. Institutions that are characterized by crowding and frequent
skin-to-skin-contact (such as schools, college dorms, daycare centers, correctional
facilities, military barracks, and gyms) should develop and maintain policies that
promote consistent adherence to handwashing and hygiene guidelines.
Household members often
carry the MRSA bacteria
Nonprofit Organization
U.S. Postage
P  A  I  D
Permit No. 2563
Philadelphia, PA 19104
Issue Brief
Published by the
Leonard Davis Institute
of Health Economics
University of Pennsylvania
3641 Locust Walk
Philadelphia, PA 19104-6218
215.898.5611
fax 215.898.0229
ADDRESS CORRECTION REQUESTED
This Issue Brief was supported by the Agency for Healthcare Research and Quality, Centers for Education and Research on Therapeutics, University
of Pennsylvania School of Medicine (U18 HS016946).  The opinions expressed are those of the authors and not the funding agency.
Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104.
Janet Weiner, MPH, Associate Director for Health Policy, Editor
David A. Asch, MD, MBA, Executive Director
Issue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, and social and ethical
issues that influence how health care is organized, financed, managed, and delivered in the United States and internationally. The LDI is a cooperative
venture among Penn schools including Medicine, Nursing, Dental Medicine, Communication, and Wharton, and the Children’s Hospital of Philadelphia.
For additional information on this or other Issue Briefs, contact Janet Weiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).
© 2009 Leonard Davis Institute
Visit us on the web at www.upenn.edu/ldi
POLICY IMPLICATIONS
Continued
• New strategies for preventing MRSA transmission in the community require an
improved understanding of the dynamics of colonization and infection among
adults and children within households. A longitudinal study is ongoing at the
University of Pennsylvania to better understand how MRSA spreads within
household members and the factors contributing to the spread of MRSA within
the household.
• The development of antibiotic-resistant organisms, in general, is linked to overuse
and improper use of antibiotics. It is possible that prior antibiotic use is associated
with the development of MRSA infection in an individual.  Ongoing research at
the University of Pennsylvania is investigating the link between antibiotic use and
MRSA in children.  If this link is confirmed, it would add another compelling
argument for the judicious use of antibiotics.


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