Nursing

FOUR SMALL LESIONS appeared as harmless as drained blisters but made Clyde's hand feel like it was on fire, so he went to the emergency department (ED). A poison-ivy-like rash had started two weeks ago, after he'd been working in his woodshed. Clear drainage was oozing from small blisters near his right thumb. Without trauma or a bite injury to the area, Clyde wrote it off as a simple skin irritation or allergy. The following day, Clyde alternated between having the chills and sweating, but he did not check his temperature. About 10 days after the event, the pain in his hand started spreading up his arm.

Now, as he sat in the ED with throbbing pain he rated as 10, the nurse attending him noted his shallow respirations, and his flushed and diaphoretic face. His elevated temperature was 100.2°F, blood pressure 124/67 mm Hg, respirations 20 per minute, and pulse 102 beats per minute.

The ED physician ordered two sets of blood cultures, x-rays of the right hand, and a tetanus toxoid/diphtheria injection, 0.5 mL IM. Clindamycin (Cleocin HCl) 900 mg was given orally every six hours. Vancomycin (Vancocin, Vancocin HCl) and ciprofloxacin (Cipro, Cipro XR, Proquin XR) would be added if there was no improvement by morning. Other interventions included an infectious disease consult and a nasal swab to screen for methicillin-resistant Staphylococcus aureus (MRSA).

CONSULTS The next day, Clyde's WBC count increased to 20,000 mm³ . However, his blood cultures were negative for growth at 24 and 48 hours, and at five days. The infectious disease physician recommended oral clindamycin 900 mg every six hours, vancomycin 1250 mg IV every 12 hours, and oral ciprofloxacin 500 mg every 12 hours. Two days after antibiotic therapy was started, Clyde's right hand remained swollen and red, and was hot to touch. Multiple raised areas near the base of his thumb were draining purulent material. Clyde denied any sensory changes, and his fingers had full range of motion. To further explore the lesion, the wound was cultured, and a dry, nonadherent dressing applied. Twenty-four hours later, the laboratory reported the drainage was positive for MRSA.

At that time, a surgical consult was placed. Treatment recommendations included incision and drainage of the wound, and whirlpool use three times a day. The wound was packed with iodoform gauze and covered with a dry, nonadherent dressing, then wrapped with rolled gauze.

HOSPITAL DISCHARGE After a seven-day hospital stay, Clyde was discharged home. His diagnosis was MRSA cellulitis, community-acquired. Discharge medications included clindamycin 450 mg every six hours by mouth for one week. For pain, he was prescribed hydrocodone/acetaminophen (Vicodin) at 5 mg/500 mg at one tablet every four hours as needed for pain, and aspirin (Halfprin, Ecotrin) at one 325 mg tablet four times daily as needed. Discharge teaching also included that he contact his primary care physician if his right hand became warm to touch, or he developed a fever. In 10 days, he had a follow-up appointment with his primary-care physician. As an outpatient, his therapy included whirlpools for his right hand three times a week, along with dressing changes and wound packing. The whirlpools and dressing changes helped remove purulent drainage and old scabs so that his wound healed. The whirlpool helps healing by promoting circulation and removing exudates, both of which reduce infection. The warm water of the whirlpool dilates the blood vessels, which aids in the transport of oxygen and nutrients to the wound. Whirlpool therapy also increases antibodies, leukocytes, and systemic antibiotics, and softens and loosens necrotic tissue and wound exudate. The mechanical effects of the whirlpool stimulate the formation of granulation tissue, and the warm water induces sedation and analgesia.¹

Whirlpools are like any other reusable medical equipment and should be disinfected according to the manufacturer's instructions. This is particularly important when a patient such as Clyde is infected with a resistant organism. The sides, bottom, and turbines of the whirlpool must be disinfected. The cleaning agent must remain in contact for at least five minutes before it is scrubbed and rinsed. The turbines are cleaned with household bleach. The bleach is mixed in a solution of one part bleach to 10 parts water and allowed to circulate though the running turbines with hot water for 10 minutes. Hot water also should be used to rinse the tub and then allowed to drain. The final step is to towel dry the tub.² Whirlpool disinfectants can adversely affect skin and tissues. For instance, chlorine and its byproducts can cause allergic reactions.³ Cleaning agents also can cause redness, burning, and irritation to intact skin.⁴

FOLLOW-UP CARE At his follow-up appointment, Clyde's physician noted that the wound was improved, so he discontinued the wound packing. The WBC count also improved, at 10,700 mm³ . An additional week of clindamycin 450 mg every six hours was prescribed, as well as an additional week of physical therapy whirlpools and dressing changes three times per week. Two weeks later, Clyde returned to the surgeon, who was pleased that the hand had healed, and only a small scar was visible on the first web space. His fingers were just a little bit stiff when he made a fist.

During this visit, the physician also ordered another culture of his nares. A repeat nares culture should not be performed until a week after antibiotics are completed. Clyde had been off antibiotics for over a week, and it had been more than 10 days since he had completed his nasal mupirocin.⁵ A total of three sets of nares cultures should be obtained while the patient is off antibiotics.

EPIDEMIOLOGY Staphylococcus aureus easily grows on human skin and mucus membranes.⁶ However, one type of Staph—methicillin-resistant Staphylococcus aureus (MRSA)—is a form of bacteria that is resistant to a number of antibiotics, including the beta-lactam group, such as oxacillin (Bactocill), penicillin (Pfizerpen), amoxicillin (Amoxil, Trimox), cephalosporins (Cefazolin, Cephalexin) and carbapenems (Ertapenem, Doripenem).⁶ MRSA is also resistant to other antibiotic classes, such as the aminoglycosides (Gentamicin, Streptomycin), macrolides azithromycin (Zithromax), and fluoroquinolones such as ciprofloxacin (Cipro, Ciproxin).⁷

MRSA infections increase length of hospital stays, healthcare costs, and mortality.⁸ The average hospital stay costs $7,600, but MRSA infections can raise that cost to $14,000.⁹

Community-acquired MRSA (CA-MRSA) was first acknowledged in the 1980s.¹⁰ The Centers for Disease Control and Prevention (CDC) is working with state and local public health departments to gather epidemiologic data on CA-MRSA infections. According to the CDC, there are at least three different strains of Staphylococcus aureus that cause CA-MRSA in the United States.¹¹

In the beginning, it was suspected that community-acquired MRSA infections could be traced to healthcare facilities, including hospitals. Over the last decade, however, CA-MRSA infections have occurred without any exposure to the healthcare setting. CA-MRSA has become more distinct, both genetically and epidemiologically, from healthcare-acquired MRSA (HA-MRSA). This has led many experts to contend that CA-MRSA isolates did not, in fact, emerge from local healthcare-acquired MRSA strains.¹⁰

Today, CA-MRSA is defined as MRSA that occurs in individuals who have not been hospitalized within the past year or who have not undergone any medical procedures such as outpatient surgery, catheter placement, or dialysis.⁶