Community Acquired Infections on the Rise

Five or six years ago, if Dr. Michael Edmond treated an outpatient for an antibiotic-resistant staph infection, the person had almost always picked up the bug during hospital care.

Not anymore.

"We are seeing so many people in the community who are healthy, often young, have no underlying disease, have never been in the hospital, and they are getting MRSA infections," said Edmond, a professor of internal medicine, epidemiology and community health at VCU Medical Center.

MRSA is methicillin-resistant Staphylococcus aureus, a staph bacteria that is no longer cured by methicillin and similar antibiotics that are the usual first choices for treating staph infections. MRSA can cause mild skin infections that show up as abscesses or boils, Edmond said. Or it can be severe, leading to potentially lethal complications, including pneumonia and blood poisoning.

Two recent reports suggest the MRSA problem is getting worse.

Last week, the federal Agency for Healthcare Research and Quality released a report showing that MRSA hospitalizations in the United States increased from 38,100 in 1995 to 128,500 in 2000 to 368,800 in 2005.

In June, the Association for Professionals in Infection Control and Epidemiology released a survey suggesting that MRSA cases in health-care facilities are eight to 11 times more common than previous estimates.

Understanding what is going on with MRSA in hospitals is important, experts say, because increasingly MRSA infections are showing up in the community. Evidence suggests there are new strains, and there is fear community-associated MRSA will become just as hard to treat as the infections that hospitals struggle to suppress.

"The staph aureus that's in the hospital gets exposed to a fairly broad range of antibiotics over time," said Dr. Christopher Novak, a medical epidemiologist at the Virginia Department of Health. "And it's kind of selecting or breeding for the strongest strain. Over time it can acquire resistance to a very wide range so that there is almost nothing left to treat it. There are a few antibiotics that are left, but typically they are IV drugs and they are very strong."

As people leave the hospital or nursing homes with staph infections or with it colonized but not causing an infection, they can expose others to it, said Dr. Richard Wenzel, an infectious-disease expert at VCU.

"We are sending patients home with IVs to complete their therapies," Wenzel said. "They have catheters and come back periodically to get their chemotherapy. All those kinds of things. People are carrying the organism home. At the same time the community-acquired MRSA in the last 10 years has become a global problem.

"There are two epidemics, and the traffic is going in both directions," Wenzel said.

Dr. Thomas Murphy, a family medicine physician at the Patient First office near Parham and Woodman roads in Henrico County, said patients will come in with a raised, reddish bump they think is a spider bite.

"At one time we never used to worry about methicillin-resistant staph," Murphy said. "We used to treat them with cephalosporins or a combined antibiotic. That would be the end of it. We are more cognizant of the fact they may need to be treated with Bactrim or doxycycline."

In healthy people, infections generally clear up, he said. "If you have people with ... multiple medical illnesses, they may need more advanced treatment to get rid of it," Murphy said.

Edmond, at VCU, says everyone is probably exposed from time to time. "When I see patients that are getting it over and over, some of the things we try to do is we culture their nose to see if they are carrying it in their nose. If they are, there are antibiotic ointments we can put in their nose to try to decolonize them from the organism," he said.

Outbreaks have been reported among members of sports teams, in prisons and jails and other places or situations where folks are in close contact.

Virginia high school coaches get information on preventing skin infections among players, said Dr. Vito Perriello, a Charlottesville pediatrician and chairman of the Virginia High School League's sports medicine advisory committee. Perriello said he has heard of outbreaks among a rowing team, wrestling teams and football teams.

"When we were growing up, you took off your sweaty athletic stuff, stuffed it in your locker and came in the next day and put the same stuff on," Perriello said. Now players are advised to shower and change clothes after practice or play, he said.

While doctors may not do cultures on every patient suspected of having staph, cultures can be important to understanding the epidemic, Novak said. "You see exactly what it is resistant to and what it is sensitive to and you use the right drug to treat it.

"If you are a physician out there, and you know your patient was on dialysis and was in the hospital regularly, you might have a suspicion that it's going to be slightly harder to treat than, say, the boy who comes in from soccer practice who has a big abscess," Novak said. "You might think perhaps it's going to be more susceptible, but you still really should get the cultures and be sure. You don't know if that boy had contact with a mom or grandma or father who ended up in the hospital and brought home a more resistant form."

By Tammie Smith: Staff Writer at Media General's Richmond Times-Dispatch.