Guidelines for Health Professionals on Outpatient Management of Skin and Soft Tissue Infections in the Era of Community-Associated MRSA (added June 2008)
These recommendations from DHEC are based on guidelines from the Centers for Disease Control and Prevention, the American Medical Association and the Infectious Disease Society of America.
- Download 11 x 17 color poster of Outpatient Management Guidelines (pdf)
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- Download 8 ½ x 11 two-page black and white mini-poster of Outpatient Management Guidelines (pdf)
What South Carolinians Need to Know About Community-Acquired MRSA
Recently, several otherwise healthy students in New York and Virginia died from drug-resistant Staph infections. These stories made national headlines and alarmed many people, especially parents, who wondered if their children could get the same infection.
The students who died had a serious Staph infection called community-acquired MRSA. MRSA stands for methicillin-resistant Staphylococcus aureus. MRSA is a type of Staph infection that cannot be cured by common antibiotics. Stronger medicines or treatments are needed.
The information below, from the South Carolina Department of Health and Environmental Control will answer many of your questions about MRSA and help you protect your family’s health. DHEC is also working with local health departments and school districts to address questions about MRSA in schools.
These guidelines and answers have been developed at a time when new information about the epidemiology of MRSA in the US and about approaches to prevention of MRSA in community settings is becoming available. Therefore, some of what is presented here may be modified as new information and national guidelines become available.
However, recommendations regarding key important hygienic measures to prevent the spread of MRSA, such as good hand-washing and bathing, the need to keep wounds covered, and the importance of not sharing personal items such as towels and razors are well-established and not likely to change.
Questions about Community-Acquired Methicillin Resistant Staphylococcus aureus (CA-MRSA)
- What is Staphylococcus aureus?
- What is MRSA (methicillin-resistant Staphylococcus aureus)?
- What is Community-Acquired MRSA (CA-MRSA)?
- Why are we hearing so much about MRSA?
- What are the symptoms of CA-MRSA?
- What should I do if I think that I have MRSA? Can it be treated?
- Is it possible that my Staph or MRSA skin infection will come back after it is cured?
- Do people die from CA-MRSA infections?
- If I have a Staph, or MRSA skin infection, what can I do to prevent others from being infected?
- How can I prevent Staph or MRSA skin infections?
- How can I avoid getting MRSA at my health club?
- How can my school prevent MRSA?
- If my child uses athletic facilities (such as the weight room) or is involved in athletics, what additional measures can be taken to prevent and control MRSA infections within the athletic setting?
- What can teachers do to prevent the spread of MRSA in the classroom?
- Information for School Nurses and Administrators: What should I do if a student in my school is reported to have MRSA?
- Are children with MRSA required to stay out of school?
- Do I need to alert parents and staff if a student has a MRSA infection?
- Are there special considerations for students with immune suppression or HIV?
- How can I get more information about MRSA?
- Are there websites where I go to get additional information?
- Do I report cases of MRSA to DHEC?
Staph is a type of bacteria. Up to one-third of all people carry Staph on their skin or in their nose. They are “colonized,” but not infected, with Staph. They have no symptoms, yet they can pass the germ to others.
Ordinary Staph is usually harmless unless it enters the body through a cut or wound. Even then, it typically only causes minor skin infections (such as pimples and boils) that heal without antibiotics. In fact, Staph is one of the most common causes of minor skin infections in the United States.
Unfortunately, ordinary Staph can also sometimes lead to a more serious infection called MRSA. People at highest risk are the elderly, people with open wounds or weak immune systems, and very young children. MRSA is seen most often in nursing homes and hospitals, where Staph bacteria can get into surgical wounds and the bloodstream and cause a serious form of pneumonia.
MRSA is a serious type of Staph infection that cannot be cured by common antibiotics (methicillin, oxacillin, penicillin and amoxicillin). MRSA is treatable with other drugs and medical procedures. An estimated 1.2 million hospital patients in the United States are infected with MRSA each year; another 423,000 US hospital patients are colonized with MRSA each year.
Remember that many people carry Staph infection without having any symptoms. While 25% to 30% of the population may be colonized with Staph, only about 1% of people have been colonized with MRSA.
Most MRSA cases occur in nursing homes and hospitals. However, 10 to 15 percent of MRSA cases occur in people who have not been in the hospital, or had surgery, dialysis, catheterization or other medical procedures in a year or more. These cases are called community-acquired MRSA (CA-MRSA). These usually show up as skin infections— pimples or boils or abscesses— and usually occur in people who are otherwise healthy.
Obviously, the tragic deaths of several children from community-acquired MRSA have focused attention on the infection. However, MRSA is not really a new infection. MRSA has been around in nursing homes and hospitals for several decades and in the community-at-large since the 1990s.
Many hospitals are beginning to use surveillance systems to track bacterial outbreaks, so the public is hearing more about these infections.
In the past, MRSA infections were mostly seen in hospitals. Now they are prevalent in community settings, too. Because the occurrence of these infections in community settings is relatively new, some people become alarmed when they hear about them.
The news media are also carrying more stories about MRSA where they use the term “super bug.” The term "super bug" may make people think that there are no antibiotics that will work against MRSA. This is not the case.
The most common signs of any sort of Staph infection are:
- Redness, swelling, and tenderness at the site of what may look like a pimple
- A painful, pus-filled rash
- What appears to be a cluster of severely infected spider bites,
- Impetigo with fluid-filled blisters
- Blisters or pus-filled boils or abscesses.
Sometimes people will notice more than one sore at a site.
Some people with MRSA will have multiple lesions (sores) that look like spider bites. The involved site is red, swollen, and painful and may have pus or other drainage.
More serious Staph infection may lead to blood stream infections or pneumonia. Symptoms may include shortness of breath, fever, and chills.
If you think you have an infected wound, see a medical care provider. MRSA can be diagnosed only through a lab test.
MRSA infections can be treated. Treatment depends on the site and severity of the infection. Not all infections require oral antibiotics. However, if antibiotics are prescribed, take them exactly as instructed. If the infection has not improved within a few days after seeing a health care provider, contact the provider again.
Yes. A Staph or MRSA skin infection may come back after it is cured. To prevent this from happening, follow your health care provider’s directions while you have the infection, and practice the hygiene steps described below.
On rare occasions, community-acquired MRSA can cause life-threatening illness and death, even when treated quickly. However, in the vast majority of cases, community-acquired MRSA infections are limited to the skin and do not result in severe complications.
You can keep from spreading Staph or MRSA skin infections to others by following these steps:
- Cover your wound. Keep wounds that are draining fluid or pus covered with clean, dry bandages. Drainage from infected wounds may contain Staph and MRSA. Follow your health care provider’s instructions on proper wound care. Discard bandages or tape with the regular trash.
- Clean your hands frequently. You and your family members should wash your hands frequently with soap and warm water or use an alcohol-based hand sanitizer, especially after changing the bandage or touching the infected wound. The same goes for anyone else in close contact.
- Do not share personal items. Avoid sharing personal items such as towels, washcloths, razors, clothing, or uniforms that may have been exposed to the infected wound or bandage. Wash sheets, towels, and clothes with hot water and laundry detergent. Drying clothes in a hot dryer, rather than air-drying, also helps kill bacteria.
- Talk to your doctor. Tell health care providers who treat you that you have or had a Staph or MRSA skin infection.
Practice good hygiene:
- Keep your hands clean by washing them thoroughly with soap and water or using an alcohol-based hand sanitizer.
- Keep cuts and scrapes clean and covered with a bandage until healed.
- Avoid contact with other people’s wounds or bandages.
- Avoid sharing personal items such as towels or razors.
- Teach children to wash their hands regularly, especially before eating and after using the bathroom.
- Be sure your family members use antibiotics properly. Take all that are prescribed, even if the symptoms stop before the prescription is used up. Do not share prescriptions.
- Children who participate in sports should wash their hands after each practice and game. They should not share equipment, uniforms, towels, or other personal items such as razors. Always wash uniforms and towels with hot water and detergent after each use.
MRSA is transmitted most frequently by direct skin-to-skin contact. You can protect yourself from infections by practicing good hygiene. Keep your hands clean by washing with soap and water or using an alcohol-based hand rub, and shower after working out. Cover scrapes or cuts with a clean dry bandage. Avoid sharing personal items such as towels or razors. Use a barrier such as clothing or a towel between your skin and shared equipment. Wipe equipment surfaces before and after use.
The Massachusetts Department of Health and the Tacoma-Pierce County Department of Health in the State of Washington have developed excellent MRSA materials aimed at schools. Below, you will find links to their Web sites and to other sites that may be useful.
13. If my child uses athletic facilities (such as the weight room) or is involved in athletics, what additional measures can be taken to prevent and control MRSA infections within the athletic setting?
Athletes, athletic personnel, and parents can help prevent and control MRSA infections within athletic settings by following these simple health and hygiene practices:
- Wash hands frequently with soap and water, especially after using any sports facilities.
- Avoid sharing personal items such as towels, washcloths, razors, clothing, or uniforms. These and similar items may have had contact with an infected individual or potentially infectious material.
- Athletes involved in close contact sports should receive a total body check by the appropriate athletic personnel before any game, match or tournament.
- Individuals with an infection involving drainage who are involved in close contact sports should be excluded from participation in sporting events and practices until no drainage is present and the infected site can be adequately covered with a bandage and clothing.
- Athletes and other students should report any suspicious skin sore or boil to their health care provider, trainer or school nurse immediately. All draining wounds must be covered with clean, dry bandages during practices and games. If the draining cannot be contained, the player should be excused from activities.
- In sports involving close personal contact such as wrestling and football, players should shower with soap immediately after each practice, game, or match.
- Any cut or break in the skin should be washed with soap and water. Cuts and breaks in the skin should be covered with a new clean, dry dressing each day. Dressings should be changed before and after participation in close contact sports, and after using any sports facilities
- Coaches and players should not allow sharing of any equipment, uniforms, or towels. Equipment and uniforms should be assigned to one individual for the whole season. After each use, uniforms and towels should be washed with detergent in hot water and dried thoroughly.
- Non-washable gear such as pads or head protectors should be wiped down with alcohol after each use.
- Athletic equipment such as weight benches, wrestling or gymnastics mats, or other equipment that might have skin contact should be disinfected regularly after each practice and in-between uses. Wipe with an antibacterial solution (for example, Hibiclens) or an EPA-registered cleaner or bleach solution (1 part bleach to 9 parts water). Clean both sides of mats before rolling them up for storage.
- Students should tell their health care provider or school nurse and the appropriate athletic personnel if they have a drug-resistant Staph skin infection or have a history of Staph infections.
Remember: Routine cleaning is all that is recommended. Because the bacteria live on the skin, they may be reintroduced into any environment at any time. Therefore, hand washing and wound care remain the best means of preventing Staph infections.
- They can observe children for open wounds. If any wounds are draining or contain pus, teachers should refer the child to the school nurse.
- Teachers should encourage children to wash their hands often, especially before eating and after going to the bathroom.
Consider taking the following steps:
- Confirm the diagnosis. This may require contacting the doctor and family of the student to get accurate medical information to the school.
- Follow routine infection control precautions. Use the following infection control precautions with a student who has an MRSA infection:
- Wear gloves when handling the student or touching blood, sweat, or other bodily fluids, or any items contaminated with these fluids. Gloves should be used before touching mucous membranes and non-intact skin. Gloves should be removed after use and hand washing performed before touching non-contaminated items and environmental surfaces and before tending to another student.
- Linens (from cots, etc.) that may contain blood or other bodily fluids should be handled in a manner to prevent skin, mucous membrane and clothing exposure.
- Follow routine procedures for cleaning the environment. In general, use routine procedures with a freshly prepared solution of commercially available cleaner such as detergent, disinfectant-detergent or chemical germicide.
Children are excluded from School and childcare based on the SC School and Childcare Exclusion Rules.
- Draining Lesions:
Exclude children with draining lesions that cannot be covered with a dressing, or draining lesions that are covered with a dressing but drainage saturates dressing, until drainage stops and the child has received at least 48 hours of effective antimicrobial treatment.
- Non-Draining Lesions:
Children who do not have draining lesions, who have antibiotics prescribed, may return to school after they have received at least 48 hours of effective antimicrobial treatment and lesions are showing signs of healing (decreasing in size). Children who do not have draining lesions, who do not have antibiotics prescribed, may return to school once lesions are showing signs of healing (decreasing in size).
Children with lesions on uncovered skin, or with lesions that are draining or oozing, even if covered, may not participate in close contact sports or other athletic activities.
- Contact Precautions
Contact precautions, including appropriate disposal of possibly infectious materials, must be used if/when dressings are changed in the school or childcare setting.
DHEC may change these recommendations in the event of outbreaks or clusters of illness.
Typically, it is not necessary to inform the entire school community about a MRSA infection. When MRSA occurs within the school population, the school nurse and school or district medical consultant should determine, based on their medical judgment, whether some or all parents and staff should be notified. You may contact your local public health department for guidance on responding to MRSA cases and clusters.
Students with weakened immune systems may be at risk for more severe illness if they are infected with MRSA. These students should follow the same prevention measures as all others to prevent Staph infections, including practicing good hygiene, covering wounds, cuts and abrasions with clean dry bandages, avoiding sharing personal items such as towels and razors, and contacting their doctor if they think they have an infection.
Contact your local DHEC public health department, or go to one of the listed Web sites. You can find local DHEC public health department numbers by going to http://www.scdhec.gov/health and clicking on the name of your county.
- CDC Information on CA-MRSA for the Public
- From the CDC: Frequently Asked Questions about MRSA in Schools
- CDC Information on CA-MRSA for Healthcare Professionals
- CDC-sponsored MRSA Educational posters
- South Carolina School and Childcare Exclusion Rules
- SC DHEC List of Reportable Conditions
- Guidance for School Health Professionals from the Massachusetts Department of Health
- Guidance for School Athletics Professionals from the Massachusetts Department of Health
- MRSA Toolkit for Middle and High Schools from the Tacoma-Pierce County (WA) Health Department. The Toolkit includes information for athletic departments, classrooms and custodial staff.
- Cleaning Checklist for School Athletic Programs from the Tacoma-Pierce County (WA) Health Department (pdf)
- School Custodian Guidance from the Tacoma-Pierce County (WA) Health Department (pdf)
- Information about Community-Associated MRSA from the Charlotte-Mecklenburg (NC) Health Department, including a link to a video on MRSA prevention for sports teams
- National School Public Relations Association (NSPRA)
- MRSA Toolkit for Middle and High Schools, Tacoma/Pierce County Health Department
- Classroom risk for transmission of MRSA, Children's Hospital in St. Louis (pdf)
Beginning in January 2008, clinical laboratories must report blood cultures that are positive for methicillin-resistant Staphylococcus aureus as defined on the DHEC List of Reportable Conditions. Information about this reporting in found in the Winter 2008 edition of the Epi Notes (pdf), available from the DHEC Bureau of Disease Control.
- Outbreaks of Healthcare Associated MRSA
Outbreaks of MRSA in healthcare facilities should be immediately reported to DHEC by the facility as defined on the DHEC List of Reportable Conditions.
- Outbreaks of Community Acquired MRSA (CA-MRSA)
- Outbreaks of MRSA skin and soft tissue infections are associated with group settings where close contact may occur, such as childcare, athletic teams, prisons, and other residential facilities. Outbreaks can occur in schools, but are usually associated with an athletic team or other sharing of common equipment. Routine hygiene and cleaning practices found via the links above are effective in preventing and controlling CA-MRSA outbreaks.
- Confirmed or suspected CA-MRSA outbreaks should be reported to DHEC immediately by phone. If you have any questions about reporting a possible CA-MRSA cluster, please contact your local public health department. (pdf)
- Reporting of possible clusters of CA-MRSA cases is consistent with South Carolina law requiring the reporting of diseases and conditions to your state or local public health department. (State Law # 44-29-10 and Regulation # 61-20) as per the DHEC List of Reportable Conditions. (pdf)
- Federal HIPAA legislation allows disclosure of protected health information, without consent of the individual, to public health authorities to collect and receive such information for the purpose of preventing or controlling disease. (HIPAA 45 CFR §164.512).
Individual Cases of MRSA skin and soft tissue infections
Individual cases of MRSA skin and soft tissue infection occur commonly in all settings in the community and are not reportable. It is possible for several individual cases of MRSA skin and soft tissue infections to occur in the same group setting, such as a school, without evidence of close contact between the cases. In that event, several cases would not be considered an outbreak.