Drug-resistant staph cases should sound an alarm for tighter controls
Wound patients particularly susceptible
The emergence of vancomycin intermediate-resistant Staphylococcus aureus (VISA) in the United States should be of special concern to wound care professionals, experts caution. Because wound care involves direct contact between a health care worker’s hands and the patient’s broken skin, the risk of pathogen transmission from one to the other is higher than for patients whose skin integrity is intact.
Last summer, the Centers for Disease Control and Prevention in Atlanta released interim guidelines for preventing the spread of VISA after a case was discovered in Japan.1,2 (For a summary of the guidelines, see p. 126.)
Since the guidelines were released, two U.S. cases were identified in a one-month period. The first, in Michigan, was the first S. aureus isolate intermediately resistant to vancomycin (VISA) discovered in the United States. The patient had been treated for six months with multiple courses of vancomycin for repeated episodes of peritonitis associated with vancomycin-susceptible, methicillin-resistant S. aureus.3
In the second case, a New Jersey patient developed a VISA-associated bloodstream infection with long-term methicillin-resistant S. aureus (MRSA) colonization and repeated MRSA infections over six months. In addition, during that time the patient had vancomycin-resistant enterococcal (VRE) colonization. For most of that period, the patient was treated with multiple courses of vancomycin for repeated MRSA bloodstream infections. Last August, a blood culture from the patient grew an MRSA strain with intermediate resistance to vancomycin.3 The CDC expects similar cases to crop up as the future effectiveness of medicine’s most potent weapon against a common, virulent pathogen comes into question.
Wounds not involved yet
The good news is that all of the U.S. cases of VISA discovered have not involved wounds. "The patients who have been infected so far have had a bloodstream infection, which probably is not particularly communicable, and a peritoneal infection, which, again, is not particularly communicable," says William Jarvis, MD, acting director of the CDC’s hospital infections program. "But if you had a patient with either a decubitus ulcer or a surgical wound infection or pneumonia, the former would be much more likely to be transmitted on the hands of health care workers, and the latter might even be transferred short distances through respiratory secretions."
Preventing the transmissions among wound patients can be accomplished by following rigorous infection control precautions. However, this simple and common sense approach is often neglected or ignored entirely, even by experienced nurses, says Kathi Whitaker, RN, CETN, MSN, president of Sierra Clinical & Research Associates in Carson City, NV. "There are still a lot of folks among wound care professionals who don’t use proper infection control principles," she says.
The consequences can be significant. Whitaker recalls an epidemic of Serratia among wound patients in a midwest hospital whose cause was tracked to the failure of health care workers to wipe down a transfer board between uses. "That could easily have been prevented by following proper infection control protocols," she says.
Practicing infection control in the home health setting is an even greater challenge because the environment is out of the practitioner’s control, and foreign items, such as the nursing bag, are carried from one patient to another without regard for infection control, says Perry Ann Shewmake, RN, CETN, a nurse consultant in Satsuma, AL. "What I’d like to see when we come out of a car and go into a home is for nurses to use appropriate standard universal precautions as recommended by the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration," Shewmake says. "This is basic nursing practice. It’s nothing new, but we have to be aware of it and carry out the necessary measures. Otherwise, we become the vector for transmission of these bacteria. But we can minimize their spread by using the basic concepts of nursing, including medically aseptic technique."
Shewmake also says nurses should not carry their nursing bags into patients’ homes because it may be a rich source of bioburden and a perfect means of transporting pathogens from one patient to the next.
Practitioners must be cognizant of what are normal and abnormal flora, Shewmake adds. "But you can’t tell the difference with the naked eye, so you have to assume that for any patient who is compromised in any way, you have to keep that wound sterile. For example, instead of using 4x4s [gauze pads] from a loaf, we should use sterile 4x4s, even on a dirty wound. Just because a wound is dirty doesn’t mean it’s OK to add more dirt to it."
Whitaker recommends that practitioners who deal with wound patients take not only the standard preventive measures, such as using gloves whenever contacting the patient, but go a step further by wearing gowns and masks when coming in close contact. Goggles should be worn if a spray cleanser or aerosol is used. And, of course, practitioners should thoroughly wash their hands immediately before and after seeing a patient.
Once contracted, drug-resistant bacteria also can become a particularly serious problem for wound patients, whose immune systems are often compromised to begin with.
"These bugs can be devastating to patients with wounds. They often lose skin in great quantities," Whitaker says. "I remember one patient whose wound got infected and who then lost his skin from the umbilicus down to his thighs and genitals. Another lost greater than 30% of her skin, including more than half of the skin on her upper torso."
Whitaker adds that patients usually survive episodes of extreme bacterial infection if they’re young and not immunocompromised. But older, malnourished patients may succumb to an infection that gets out of control.
The principles of treating wound patients who have contracted a bacterial infection are no different from treating an uninfected wound. They include using medically aseptic technique and choosing the correct dressing based on the condition and type of the wound, Shewmake says.
She stresses that nurses should be as familiar as possible with the variety of wound dressings and their proper indications and application.
"I believe it’s just as big a nursing error to put the wrong dressing on a wound as it is to give the wrong medication, and no matter what, the treatment of any wound must be such that we’re not carrying any infection that may be present from one patient to the next."
References
1. Centers for Disease Control and Prevention. Interim guidelines for prevention and control of staphylococcal infection associated with reduced susceptibility to vancomycin. MMWR 1997; 46:626-628, 635-636.
2. Centers for Disease Control and Prevention. Reduced susceptibility of Staphylococcus aureus to vancomycin – Japan, 1996. MMWR 1997; 46:624-626.
3. Centers for Disease Control and Prevention. Update: Staphylococcus aureus with reduced susceptibility to vancomycin – United States, 1997. MMWR 1997; 46: 813-815.
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