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Prison Health and Self-Care: MRSA

by Michael D. Cohen MD

Introduction

There is much concern among prisoners about skin infections caused by a well-publicized germ called MRSA. This article explains what MRSA is, what you can do to protect yourself from MRSA, and how to take care of yourself if you get a skin infection caused by MRSA.

What is MRSA?

MRSA stands for Methicillin Resistant Staphylococcus Aureus.

Methicillin is one of the penicillin type antibiotics. Penicillin was one of the first drugs developed that was highly effective against bacteria that often cause skin, lung, ear, throat and other common infections.

Resistant refers to a germ’s ability to live and multiply in the presence of an antibiotic. With widespread use of anitbiotics over the last 50 years, some germs have developed the ability to survive treatment with some drugs. Penicillin resistance became widespread among certain germs commonly treated with penicillin. Methicillin was developed to re-establish the effectiveness of penicillins against these germs. Now some germs are resistant to methicillin and other penicillin-like drugs too.

Staphylococcus aureus is the scientific name for one germ that commonly causes skin infections. It is also called “staph” for short. Staph normally inhabits the skin and the nose near the nostrils. Most of the time it causes no harm. This is called colonization. When the skin is broken, or the body is weak, staph can multiply out of control and cause disease. Staph that are resistant to both penicillin and methicillin and the other penicillin-like antibiotics are being seen more frequently in skin infections.

So MRSA is the name for a group of staph bacteria that are resistant to penicillin, methicillin and other similar antibiotics that are usually used to treat staph infections.

Staph Skin Infections

People have always had skin infections. Skin infections are mostly caused by two families of bacteria, staph and another group called streptococcus or “strep”. The establishment of good personal hygiene and elimination of crowded living conditions have generally reduced the incidence of skin infections such as abscesses, boils, carbuncles, cellulitis, folliculitis, and furunculosis.

Staph can also cause pneumonia and other infections in major organs. People with weak immune systems are more likely to get these more serious infections. The immune system can be weakened by chronic illness, extremely young or old age, HIV infection, cancer chemotherapy, malnutrition and other causes. Sometimes even healthy young adults can get staph pneumonia.

Skin infections of all types occur more frequently in conditions of crowding and poor hygiene. Jails, prisons, military barracks, refugee camps and urban slums are all settings where crowded living conditions and limited opportunities to wash and bathe result in increased incidence of skin infections. Skin infections also spread easily among athletes who have frequent skin to skin contact.

Transmission and Infection

MRSA, like all other staph germs, is spread from person to person, most commonly by skin to skin contact.

For example: Someone who is carrying staph in his nose may touch his nose with his right hand. Then perhaps he shakes hands with someone else, passing the staph to the hand of the other person. That person may scratch an itchy mosquito bite on his leg, which breaks the skin and inoculates the staph onto broken skin. The bite becomes red, tender and swollen, increasing in size and tenderness over several days until it comes to a point and starts to drain pus. This is a skin abscess or boil.

Some people have called this sort of boil or small abscess a “spider bite”. There are spiders that bite. Some types of spider bites do swell up or form ulcers as skin and other tissues dissolve from the digestive juices in the spider’s venom. But most of the skin abscesses or boils observed in jails and prisons are simply the result of staph getting into the skin through small wounds.

Another example: Someone who is carrying staph on his skin is working out strenuously and sweating. He takes his shirt off to cool off and lays down bare-backed on a bench press. Sweat and staph are deposited on the bench. The next man to use the bench also has no shirt on, and he happens to have scraped his back recently and his skin is slightly raw.
Staph from the bench inoculates the raw skin of his back. The scratch becomes red, tender and warm to touch. The red, swollen, warm area spreads more widely over the next two days and he starts to get a tender lump in his arm pit on the same side as the spreading skin infection. This skin infection spreading under the skin is called cellulitis. It is more comonly caused by strep, but it can be caused by staph.

Fluids draining from a boil or skin abscess are teeming with bacteria and highly infectious. Outbreaks may occur due to contact with infectious wound drainage via contaminated surfaces, soiled bandages, clothing and bedding. Control of outbreaks involves better wound hygiene and decontamination of surfaces where transmission may be occurring, especially in medical clinics where patients are treated one after another, and in gyms where athletic equipment is shared among many people one after another.

Prevention of MRSA Infection

Good personal hygiene helps prevent exposure to staph infections, including MRSA.
Wash your hands frequently with soap and warm water. Wash your hands when you get up in the morning. Wash your hands whenever you return to your cell. Wash your hands frequently during workouts when using equipment that is used by others. Wash your hands before meals. Wash your hands after using the bathroom.

Bathe daily with warm water and soap.

Bathe as soon as possible after physical activity, contact sports or working out. Dry off after bathing with a clean towel.

Public health authorities recommend liquid soap rather than bar soap to prevent staph being spread on a bar of soap.

Don’t share personal care items such as razors, towels, bars of soap, deoderants, creams, ointments or lotions of any kind.

Keep all skin injuries such as scratches, cuts, scrapes or insect bites clean and covered to keep germs from getting into the wound.

Protect yourself from exposure to other people’s skin and sweat. Wear shirts when exercising or playing contact sports like basketball. Place a towel or cloth over the bench before laying down to use the bench press. In some public or school gyms, shared equipment with skin contact is disinfected periodically to reduce the risk of disease transmission.

Don’t scratch itchy insect bites. Scratching creates small wounds that can allow staph entry into the skin. Use a hot shower or antihistamines like diphenhydramine (Benadryl) or hydoxyzine (Vistaril) to reduce itching and avoid the urge to scratch.

Like HIV, hepatitis C and hepatitis B, MRSA can be spread on contaminated tattoo needles, injection drug works, and during sexual contact.

Avoid contact with other people’s wounds or bandages. If you do have contact with other’s wounds or bandages, always use gloves if they are available to you. Wash hands and forearms thoroughly after contact even if you do wear gloves.

In general, isolation or quarantine are not effective measures to control or prevent spread of MRSA. This is because many people carry MRSA in their nose or on their skin but are not sick. However, if a patient with a draining skin abscess is unable to keep the wound covered with a dressing, wash frequently, and generally avoid contaminating the shared environment with the wound drainage, then isolation may be necessary to protect others from his or her MRSA.

There is no vaccine for staph.

Management of Staph Skin Infections

Most staph skin infections are limited to one small local area. Throughout history the treatment of boils and skin abscesses has always been and still is to establish drainage of the liquid or pus from the infected area.

Warm dry or moist compresses for 20 minutes every four hours helps increase circulation to the infected area and allows the body’s natural defenses to concentrate there. Local heat helps bring the pus to the surface where it can drain spontaneously. In larger abscesses it may be necessary to make a surgical incision into the abscess to establish drainage.

Do not squeeze or “pop” boils or other small skin abscesses. Squeezing or pinching can damage the surrounding tissues under the skin and allows the infection to spread more easily into the newly injured area around the boil.

Drainage from a boil or abscess is full of germs. Contamination of surfaces, skin, hands and clothing enables staph to spread to other sites on the infected person, or to other people. Keep boils covered with a bandaid or dressing as well as clothing. This limits the spread of infectious drainage from the infection. Change the bandaid or dressing and shirt often, and dispose of soiled bandages in plastic bags. Wear gloves if you can when handling dressings or contacting wound drainage. Wash hands and forearms well after handling dressings even if you do wear gloves.

When clothes, towels, or bedding are contaminated with wound drainage, wash them in hot water and dry in a hot dryer to kill the germs via heat and dehydration.

Clean and disinfect objects or surfaces that may have become contaminated with wound drainage. In the free world a solution of one tablespoon household bleach in a quart of water works well as a disinfectant. Even if you don’t have a disinfectant, use warm water and soap followed by towel drying to clean soiled surfaces in your cell.

Surfaces in medical clinics such as exam tables should be protected by disposable paper liners and disinfected regularly.

Use of Antibiotics

Early in the course of infection small sores may be treated with topical antibiotic cream or ointment such as mupiricin (Bactroban) four times a day. Later stages that are spreading or enlarging will not respond well to treatment on the skin alone.

If the infection is getting bigger or more painful it may require antibiotic treatment to get it under control. Also, if there are symptoms affecting the whole body such as fever, fatigue, cough, or shortness of breath, prompt medical attention and antibiotic treatment are needed. Effective treatment of spreading infection requires antibiotics that come to the infected area in the blood. This is generally accomplished by taking antibiotic pills. In the most severe or dangerous infections, intravenous (IV) antibiotics are used in the hospital or infirmary.

People who are already sick with chronic illness (diabetes, sickle cell, liver disease, lung disease, inflammatory bowel disease), HIV infection with immune compromise, cancer chemotherapy, or take corticosteroids like prednisone regularly are at greater risk for more serious types of staph infection. People with these conditions need prompt medical attention and antibiotics with the first signs of staph infection. It may be helpful to remind the nurse, physician’s assistant or doctor that you have a chronic illness that weakens the immune system.

Not all skin infections are caused by MRSA. MRSA is not common in all communities. In areas where MRSA is not common, first line antibiotics like methicillin or a cephalosporin like cephalexin (Keflex) can be used.

Some antibiotics are not very effective for treatment of staph infections today. Macrolides like erythromycin and azithromycin (Zithromax) don’t work very well against many MRSA germs. Also, fluoroquinolones such as ciprofloxacin (Cipro) may not be very effective against MRSA either. Common antibiotics that are usually effective include clindamycin, various tetracyclines including doxycycline and minocycline, and trimethoprim-sulfamethoxazole (Bactrim or Septra).

If a boil or abscess is spreading and antibiotic treatment is going to be started, it is best to obtain a specimen from the wound drainage to send to a lab to grow the germs and test them for sensitivity or resistance to various antibiotics. This information can be used to guide treatment a few days later, especially if the infection has continued to spread in spite of the treatment that was begun.

Follow-Up

Patients with spreading skin infections or those treated with antibiotics should seek medical attention promptly if they develop signs of more widepread illness, such as fever. Also, medical followup should occur about 48 hours after the initial contact with health staff to see how the infection is responding to treatment.

Dr. Cohen has provided health care to prisoners in a large urban jail, a state prison and juvenile facilities. He has been a medical expert for civil rights organizations working to improve health care for prisoners, and helped produce the Prisoner Diabetes Handbook with the Diabetes Support Group at Great Meadow Correctional Facility in New York. Suggestions for future columns can be sent to him directly at: Dr. Michael Cohen, Prisoner Self Care, PO Box 116, Rensselaer, NY 12144.

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