Community Acquired MRSA

Julie Clark, RN and Mary Perez, RN Montgomery County Health Department April Aleman RN MUHSD

Physiology of MRSA Risk factors Preventing the Spread of MRSA

MRSA

Methacillin Resistant Staph Aureus

Staphylococcus aureus-a type of bacteria that aureuscauses most skin and soft tissue infections Unable to be killed by common antibiotics including all penicillin (Methicillin) and cephalosporins MRSA has been reported in increasing numbers among healthy persons of all ages. This is referred to as Community Acquired MRSA Grows rapidly and is difficult to kill

Results of infections
Patients infected with CA-MRSA most often CApresent with: Skin or soft tissue infections- abscesses, boils, infectionscellulitis, and impetigo Necrotizing fasciitis leading to disability Bacteremia leading rapidly fatal septicemia Endocarditis Osteomyelitis Toxic shock syndrome

Risk factors Although many patients with CA-MRSA CAinfection have no risk factors factors, THERE ARE SOME SPECIFIC RISK FACTORS:

Skin trauma (eg, "turf burns", lacerations or abrasions) A higher body mass index Cosmetic body shaving Physical contact with a person who has a draining lesion or is a carrier of MRSA Sharing equipment that is not cleaned or laundered between users

Other studies have identified the following significant risk factors: Prison residence Military personnel Comorbidities: Diabetes, Immunosuppressant illness Prior skin infection Illicit drug use Tattoo recipients Previous antibiotic use Owning a dog

WHAT SPORTS/ATHLETES ARE AT RISK? ALL ATHLETES ARE AT RISK Anyone participating in organized or recreational sports is at risk Even though little physical contact occurs in some sports skin contact or activities that may lead to spread of MRSA skin infections may take place before or after participation such as in the locker room.

ATHLETES WITH EXTRA RISK

Lineman or linebacker position in football Wrestling Rugby Football Swimmers who shave Basketball

MRSA infections start out as small red bumps that can quickly turn into deep, painful abscesses.

BOIL

BOI 2

CELLULITIS

CELLULITIS

TRANSMISSION
Touching skin, wounds of an infected person Touching a dog Sharing towels Touching dirty athletic equipment Touching used bandages

MRSA Transmission
S. aureus is most often spread to others by contaminated hands

Colonization vs: Infection

Colonization state of a microorganism living in or on a body without causing disease- even after diseaseyour infection is cleared up, and you don t experience any symptoms, you may still carry MRSA.

ASSUME THAT ALL SURFACES COULD HAVE MRSA BACTERIA AND PRACTICE

PREVENTION!

PREVENTION Protect Yourself

Practice good personal hygiene  Keep your hands clean by washing frequently alcoholwith soap and water or using an alcohol-based hand rub. Liquid soap is preferred over bar soap in these settings to limit sharing. Wash your hands after using shared weightweighttraining equipment

PREVENTION CONTINUED Shower immediately after exercise especially after there has been substantial skin to skin contact. Shower before using whirlpools Report possible infections to coach, athletic trainer, school nurse, other healthcare providers, or parents. Do not share bar soap and towels, razors , clothing
Wear protective clothing or gear designed to prevent skin abrasions or cuts Do not share ointments that are applied by placing your hands into an open-container. open-

PREVENTION CONTINUED Use a barrier between skin and shared equipment e.g. exercise machines and massage tables Avoid contact with other people s cuts and sores Wash cuts, scrapes, lesions, insect bites and sores with soap and water Do not try to treat the infection yourself by picking or popping the sore. Keep lesions clean and dry and cover them with bandages until they are healed Change dressings when soiled or damp, place dressings in a paper bag, then place in the regular garbage

How should sports equipment be cleaned? Shared equipment should be cleaned after each use and allowed to dry, including mats etc.
 Wipe surfaces of equipment to disinfect before and after use, especially if the surface has become wet with sweat with an EPA registered agent

Equipment, such as helmets and protective gear, should be cleaned according to the equipment manufacturers instructions to make sure the cleaner will not harm the item. Wash uniforms and clothing after each use. Follow the clothing label s instructions for washing and drying. Drying clothes completely in a dryer is preferred.

How should athletic facilities be managed?

Athletic facilities such as locker rooms should always be kept clean whether or not MRSA infections have occurred among the athletes. Review cleaning procedures and schedules with the janitorial/environmental service staff.  Cleaning procedures should focus on commonly touched surfaces and surfaces that come into direct contact with people s bare skin each day.  Cleaning with detergent-based cleaners or detergentEnvironmental Protection Agency (EPA) registered detergents/disinfectants will remove MRSA from surfaces.

Athletic facilities continued Non approved cleaners and disinfectants, including household chlorine bleach, can be irritating and exposure to these chemicals has been associated with health problems such as asthma and skin and eye irritation. Take appropriate precautions described on the product s label instructions to reduce exposure. Wearing personal protective equipment such as gloves and eye protection may be indicated.

Athletic facilities continued Environmental cleaners and disinfectants should not be put onto to skin or wounds and should never be used to treat infections. The EPA provides a list of registered products that work against MRSA (List H): http://epa.gov/oppad001/chemregindex.htm http://epa.gov/oppad001/chemregindex.htm There is a lack of evidence that large-scale use large(e.g., spraying or fogging rooms or surfaces) of disinfectants will prevent MRSA infections. Repair or dispose of equipment and furniture with damaged surfaces that do not allow surfaces to be adequately cleaned.

Should athletes with MRSA skin infections be excluded from participation? If sport-specific rules do not exist, in general, sportathletes should be excluded if wounds cannot be covered by a securely attached bandage that will contain all drainage and will remain intact throughout the activity. The athlete needs to told to practice good hygiene measures . Top

Athletes with MRSA continued A healthcare provider might exclude an athlete if the activity poses a risk to the health of the infected athlete (such as injury to the infected area), even though the infection can be properly covered. Athletes with active infections or open wounds should not use whirlpools or therapy pools not cleaned between athletes and other common-use commonwater facilities like swimming pools until infections and wounds are healed

Question: Do we want to send home the MRSA flyers to parents?

Preventing the Spread

Carry alcohol-based hand cleaner with you so you alcoholcan clean your hands if water and soap are not available

Acknowledgement
Epidemiology and clinical manifestations of methicillin-resistant Staphylococcus aureus infection in adults John M Boyce, MDUpToDate (16.1) PHARMACIST S LETTER / PRESCRIBER S LETTER October 006 ~ Volume ~ Number 1008 CommunityCommunity-Acquired Methicillin-Resistant Staphylococcus aureus (CAMethicillin(CAMRSA): An Update CACA-MRSA Information for the Public, Centers for Disease Control and Prevention, www.cdc.gov/ncidod

Diabetes Basics: A Training Program for School Personnel

By April Roberts Aleman RN MS School Nurse MUHSD Health Services Supervisor Based on the program developed by School Nurse Mary Zombeck RN MS CPNP

WHY IS IT IMPORTANT TO LEARN ABOUT THIS ILLNESS?

. People with this illness cannot utilize the food they eat because they are not producing insulin. The illness can have deadly complications, both short term and long term. The illness requires constant monitoring every day of their life, it becomes oppressive.

Different Types of Diabetes

Type I diabetes, also known as Juvenile Onset Diabetes, begins in childhood up until about age 20. 20. It is believed to be an autoimmune illness, but not genetic. Patient is completely dependent on injected insulin for survival.

Diabetes Type
In type diabetes, either the body does not produce enough insulin or the cells ignore the insulin. Very genetic High incidence in certain ethnic groups

Prevention: Diet and Exercise

Acanthosis Nigricans

TREATMENT
Diet and exercise The next step, if necessary, is treatment with oral anti-diabetic drugs . Anti-diabetic drugs include:
Sulfonylureas metformin phenformin rosiglitazone , pioglitazone, troglitazone. acarbose miglitol. nateglinide, repaglinide exenatide liraglutide (not FDA approved) sitagliptin pramlintide

If necessary some type 2 diabetics need to use insulin. The long term effects are the same for diabetes type one: Heart disease Heart attacks High Blood Pressure Blindness (retinopathy), Nerve damage (neuropathy) Kidney damage

Gestational Diabetes
Gestational diabetes affects about 4% of all pregnant women. We don't know what causes gestational diabetes, but we have some clues.
 The placenta supports the baby as it grows. Hormones from the placenta help the baby develop.  But these hormones also block the action of the mother's insulin in her body. This problem is called insulin resistance.  Insulin resistance makes it hard for the mother's body to use insulin. She may need up to three times as much insulin.

Diagnosis
The Classic Symptoms
They are all due to high blood sugar which because the illness is not diagnosed goes untreated until a crisis.
         

Polyphagia (frequently hungry) Blurred vision Polyuria (frequently urinating) Fatigue Polydipsia (frequently thirsty) Weight loss Poor wound healing (cuts, scrapes, etc.) Dry mouth Dry or itchy skin Recurrent infections such as vaginal yeast infections, groin rash, or external ear infections (swimmers ear)

Why is it important to take care of diabetes???

The long term effects for diabetes type I: Heart disease
Heart attacks High Blood Pressure

Blindness (retinopathy), Nerve damage (neuropathy) Kidney damage

BALANCING ACT ALL THE TIME

INSULIN

Insulin is a naturally occurring hormone that moves the glucose from the blood stream to the cells, so the body can use the glucose to work. The pancreas makes insulin as the body needs it, depending what a person eats and how much they exercise.

TOO LITTLE INSULIN Results in too much sugar in the blood Thirst as body tires to dilute blood Increased urination Sleepiness

TOO MUCH INSULIN Takes too much sugar out of the blood Not enough sugar in the blood for the brain to work. Brain will die, life will cease.

Up until Sept 2007 the standard policy in schools was as stated here.

Lawsuit against C.D.E.

Good settlement results regarding discrimination and lack of care for diabetic students. EXCEPT The settlement allows an unlicensed school employee to be trained and to administer insulin. It is believed that this practice is against the Nurse Practice Act and dangerous: school nurses are refusing to teach UAPs to give insulin. The issue still needs to be settled. The diabetes association of America is upset because there are not enough school nurses to help children.

FOOD
Food provides the body with glucose.
The brain can only use a sugar called glucose to work. Without glucose the brain will DIE in a matter of minutes!

Too much or too little FOOD

TOO LITTLE FOOD Too little food causes low blood sugar The blood sugar will be even lower if insulin is taken.

TOO MUCH FOOD Too much food causes the diabetic to gain weight The diabetic will need more insulin the more he eats If he does not take enough insulin, the blood sugar will be high If the blood sugar gets too high this causes hyperglycemia and this causes long term effects

Starch 15 CARBS Vegetable 5 Fruit 15 Fat 0 Meat 0 Milk 1

Breads, Pastas, Beans, Chips, Potatoes

Is good for every student body!!!

Increasing Exercise:
Uses glucose (sugar) Causes the level of sugar in the blood to go down (low blood sugar)

Decreasing Exercise
 

Does not use glucose/sugar If the diabetic does not eat less the sugar will get too high in the blood. If the sugar is high in the blood and the diabetic uses insulin to lower it they will gain weight. Encourage the diabetic to exercise and maintain correct blood sugars.

Is good for diabetics, but they must plan ahead and have snacks handy in case their blood sugar gets too low. May have to schedule PE at a time convenient for the diabetic in terms of blood sugar stability.

There are 3 variables that influence blood sugar beyond the triangle.

BALANCING ACT ALL THE TIME

Stress causes the blood sugar to go up. Tests, boyfriend issues, drama, girlfriend problems, home dysfunctions, bad grades, up-coming tests, no money, yelling upteachers, out of control diabetes; it all can cause the diabetic student to have a high level of glucose in their blood.

In general illness and injuries cause blood sugar to go up, unless the diabetic stops eating (or is vomiting).

Signs of low blood sugar

MOST IMPORTANT PART OF THIS TRAINING

Mild hypoglycemia Symptoms of mild low blood sugar usually develop when blood sugar falls below 60 to 65 mg/dL Nausea. Extreme hunger. Feeling nervous or jittery. Cold, clammy, wet skin; excessive sweating not caused by exercise. A rapid heartbeat (tachycardia). Numbness or tingling of the fingertips or lips. Trembling.

Moderate hypoglycemia
MOST IMPORTANT PART OF THIS TRAINING

If blood sugar continues to fall, the nervous system will be affected. Mood changes, such as irritability, anxiety, restlessness, or anger. Confusion, difficulty in thinking, or inability to concentrate. Blurred vision, dizziness, or headache. Weakness, lack of energy. Poor coordination. Difficulty walking or talking, such as staggering or slurred speech. Fatigue, lethargy, or drowsiness.

Severe hypoglycemia The symptoms of severe low blood sugar develop when blood sugar falls below 30 mg/dL and may include: Seizures or convulsions. Loss of consciousness, coma. Low body temperature (hypothermia). Prolonged severe hypoglycemia can cause irreversible brain damage and heart problems, If emergency medical treatment is not provided, severe hypoglycemia can be fatal.

Denial and Hypoglycemic Unawareness

Tighter diabetic control is achieved through intensive insulin therapy; however, an unwanted consequence of this therapy is a threefold increase in severe episodes of hypoglycemia Developmentally, children may also lack the cognitive and emotional sophistication to develop adaptive coping strategies in the face of threatening experiences related to hypoglycemia. hypoglycemia.

Treatment for hypoglycemia

FoodFood-Carbohydrates, simple then complex
Juice Chips Fruit Bagels, etc

Glucose Tabs Gucose Gel Glucagon

Glucagon Procedure
Essential Steps
Verify signs of severe low blood glucose: Unable to swallow; Uncooperative; Combative; Unconscious. Place student on side or in upright position if restless/uncooperative Have someone call paramedics, parent, and school nurse Place one of the following in cheek pouch closest to ground and massage: 15 gm. of Glucose Gel If student becomes unconscious or starts to seize, give Glucagon Perform first aid for seizure When student is able to swallow give sips of regular soda pop (not diet) as tolerated until paramedics arrive. When paramedics arrive, student will be transported for medical care. Document in aeries

HYPERGLYCEMIA High Blood Sugar

Excessive thirst Fatigue, weakness Increase in number of trips to the bathroom Blurry vision Diabetic ketoacidosis

HYPERGLYCEMIA Treatment
Water, LOTS Exercise Insulin Re test after 0 to 30 minutes, if stable return to class

MUHSD Standard

Accommodations

Students can check their blood sugar anywhere on campus including in class Students can eat and drink in class Students can go to the restroom as needed Students can use the health office as needed.

CONCLUSION

Together we can help the diabetic student take good care of themselves, attend school, participate in student activities, and enjoy life.