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MRSA Infections and their Complications

Discuss about the Department for Health and Ageing.

MRSA stands for Methicillin-resistant Staphylococcus aureus isknown as a flesh eating bacteria. It results in many infections that are often difficult to treat. This kind of bacteria can also be called as multi-drug-resistant Staphylococcus aureus or oxacillin-resistant Staphylococcus aureus (ORSA) (Davies, & Davies, 2010). Antibiotics are consider to be a wonder drug that work against many infections, but real wonder is the there a many microbes that have developed antibiotics resistance. This happen due to the overuse of antibiotics. MRSA is one such microbe that has developed resistance towards beta-lactam antibiotics. Such bacterias are also called as superbugs. The people with weak immune system, open wounds and invasive devices are more exposed to such bacteria in comparison to general public. When the Methicillin was being used to treat ‘staph’’ infections, eventually the bacteria called as Staphylococcus became resistant to Methicillin and turned into more harmful bacteria called as MRSA.

Methicillin-resistant Staphylococcus aureus (CA-MRSA) is a significant bacterial pathogen that may create various challenges to the health of an individual. This kind of infection includes skin tissues. The methicillin resistance gene is carried by the mobile genetic element (Branger et al, 2003). The staphylococcal cassette chromosome, which is also called as mec(SCCmec), differs in genetic composition and size. The genetic structure of the hospital-acquired MRSA strains includes combination of the ccr and mec gene complex (Branger et al, 2003). According to the study of Branger et al, (2003) “SCCmec is integrated in the chromosome of MRSA at a unique site (attBscc), which is found inside an open reading frame (orfX) of unknown function” (Pray, 2008). The new gene variation arises in the population of the bacterium, this happen through the process of random mutation. When the single bacterium individual experience genetic mutation, the survival ability of the bacteria increases through mutation, which makes it antibiotic resistant (Tewhey et al, 2012).

Any person can be colonized and get infected by MRSA, but some of the people are considered to be at higher risk of this bacterium. The patients, who have any kind of surgical wound or have received IV are at high risk of infection. The complications increase for the people, who are hospitalized for prolonged period (Boucher, Miller, & Razonable, 2010). As, this infection is resistant to treatment, it can cause serious complications and can also result in to severe widespread. The major complication is that infection on skin can also result in tissue death. Some of the other complications and impact on other body parts are, it can cause spinal or brain abscess (also understood as nervous system infection), Infection in connective tissue, infection in lining membrane of the heart, bone marrow infection (called as Osteomyelitis) and Septicemia. The bacterium can also result in kidney failure, throat infection (Pharyngitis), joints infection and respiratory infection (Pneumonia).

Standard and Contact Precautions

MRSA infection is found in the patients, who are more exposed to open wounds, low socio-economic status, unhealthy living, history of soft tissue infection and those who have used outpatient or emergency care. The infection takes place through a process of chain. The chain of infection includes the host or reservoir, portal of entry and exit and link of transmission. Reservoir or host could be any one with uncleaned or surgical wound (Juraja, 2007). The sites of wound are more likely to be infected. Thus, in the case of MR. Jones host could be the location from where he took IV heroin. The route of transmission could be the direct contact with another person’s wound, infected material or through contaminated area. The portal of entry or exists is the wound area. Mr. Jones is a susceptible host due to his weak immunity. He had a history of IV heroin and homelessness, which explains about his unhealthy living.

The presence of MRSA infection is very serious. This requires many precautions, so that infection may not get worse. There are standard precautions and contact precautions. Standard precautions are applied for every patient suffering with MRSA infection and contact precautions are for those patients who require isolation and are restrictive.

Standard Precautions: These precautions include hand hygiene after touching contaminated items, blood fluids, excretions and other secretions. Gloves should always be worn when there is a chance of contact with blood, mucous membrane,     or contaminated skin. It also requires protecting mouth, eyes and nose in case of blood splash (Mehta et al, 2014).

Contact Precaution: These precautions are taken when colonization of the infection is found. Patient should be kept in isolation (Siegel et al, 2007). Gloves should be worn before touching patient’s intact skin. Nurse should also wear gown before entering to patient’s room and should remove after leaving room, ensuring that skin do not get touched to any contaminated surface of gown. Movement and transport of the patient should be limited.

For the management and prevention of the wound, it is necessary to educate patient about self care and self wound management. Nurse should educate patient by providing the information about the infection, how it is caused, how it can be treated and what contact precautions should be taken. The patient should be informed about the importance of routine cleaning of the wound. The prescribed medication is very essential, thus patient should be informed and educated about importance of adherence to medication (Coia et al, 2006). The combined strategies of standard and contact precautions should be informed to the patient. Patient should be educated about keeping the wound clean, covered and dry. Patient should also wash hands immediately after touching skin or infected area. Nurse should also inform patient that they should not throw bandages, but they should keep them in plastic bags and throw in dustbins (Department for Health and Ageing, 2013). Treatment is necessary, so patient should adhere to treatment prescribed by physician.

Wound Healing Process


The process of wound healing is classified in three main healing process, these are primary, secondary and tertiary. The wounds are classified on the basis of intention healing of the surgical wounds. Primary intention wound is the wound where the surface is closed after healing. Such wounds heal very quickly and leave very minimal scars (Doughty & Sparks-Defriese, 2007). They also heal quickly if the secondary infections and secondary breakdowns are prevented. The secondary wounds are the wounds that are left open and are healed by the formation of a scar (Doughty & Sparks-Defriese, 2007). Such wounds are very extensive and results in considerable amount of tissue loss. The repair time is very long and scars are very big and visible in secondary intention wounds. The epidermal barrier is lost in such wounds and they are more exposed to infections. The delayed closure in the wounds is classified with tertiary intention healing. These wounds require more connective tissue and are healed by secondary intentions (Doughty & Sparks-Defriese, 2007).

Whether the wounds are healed by primary intentions or secondary intention, thr process of wound healing is very dynamic (Clark, 2013). This whole process can be divided in three main phases, inflammatory phase, proliferation phase or maturation phase. Inflammatory phase is called as the natural response of the body towards the process of healing. After the wound is caused, the wound bed contract and the blood clot is formed. As the process of haemostasis is achieved, blood vessels start dilating white blood cells, enzymes, nutrients and antibodies to the wounded part (Clark, 2013). The process of inflammation is characterized with pain, heat, oedema and functional disturbances. Proliferation is the process, where the wound start to rebuilt with the help of new granulation tissues. Healthy granulation is dependent on sufficient receiving of nutrients and oxygen from the blood vessels. Maturation of the final phase of wound healing and characterized by wound closing. Remodelling of collagen takes place from type III to type I in this phase (Clark, 2013).

According to Dowsett & Newton (2005), wound bed preparation is defined as “the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures” (p.58). The clinicians optimize the condition of the wound on the preparation of wound bed in order to increase the healing process. Wound bed healing is the concept through which clinicians focus on the factors affecting healing of the wound and identify the main reasons behind the problem. For this process the proper care plan is applied for healthy tissue granulation.

Wound Bed Preparation and the TIME Framework

TIME framework is used to implement the process of Wound bed preparation. TIME includes the four main components; these are T- tissue management, I- control of infection and inflammation, M- moisture imbalance and W- Advancement of the epithelial edge of the wound (Dowsett & Newton, 2005). This framework is very effective in identifying the barriers among the healing process.


For the purpose of wound management, it is very important that the patient should be considered as the whole, and nursing professional must not only consider the hole of the wound. The wound management nurse disagree with betadine-soaked gauze packing as a dressing choice for Mr Jones’s cavity wound because this kind of dressing is contradicted with various reasons. The first reason is that betadine-soaked gauze packing is not able to control the excess amount of the exudates that is being produced by the wound cavity. This kind of packing can also lead to macerating of the surrounding peri-wound skin. When the gauze is dried out it can result in immense pain and damage of the tissue while removal. Such gauze may require analgesia before removal. “The proliferation phase of the wound healing is also affected by the drying of gauze, as it prevents the migration of the fibroblasts across the wound bed and delaying wound closure” (Cartlidge-Gann, 2008). Aquacel Ag ribbon, which is a dressing with anti-microbial properties can be used for Mr. Jones.

One of the contemporary strategies for the wound management is the use of Silver impregnated dressings. Since ages, silver is known to have antiseptic properties. Silver is incorporated in various wound management dressings, these dressings are hydrocolloids, gauze, creams, foams and various gels. It is also found that most of the pathogens are killed invitro with the concentration of 10-40ppm (Lansdown, 2006). The evidence based study of Lansdown, (2006) states that all the microbes found in the MRSA wounds are killed by Nanocrystalline silver. The epidermal cells of the skin absorb silver in the dressing and induce the production of metallotheine. This increases the process of DNA and RNA synthesis with increased uptake of copper and zinc. This whole process aids in healing of wound. The advantage of this kind of wound management strategy is that it improves the healing process and disadvantage is that this strategy is delivered in the form of salt that limits the widespread biological use (Lansdown, 2006).

Poor Nutrition: Poor nutrition can reduce the progress of healing process. During the process of wound healing human body requires more amounts of Vitamin A and C, proteins and calories. Thus, poor diet hampers the healing process. The nutritions are very important for the new tissues to form and heal the wound (Guo & DiPietro, 2010).

Nursing Considerations for Wound Management

Smoking: According to the study of Rayner, R. (2006), delayed process of healing is highly affected by smoking. It is one of the leading causes that affect the normal functioning of the arterial endothelial cells. Nicotine, tar, hydrogen cyanide, nitric oxide and carbon monoxide results in formation of chalones and reduce epithelialisation (Rayner, 2006). The vasoconstrictive effect of single cigarette, works up to 90 minutes. The worst part of smoking is that nicotine hampers the proliferation phase of wound healing and transportation of oxygen, which is very vital for the healing of a wound (Rayner, 2006).

Substance Abuse: Substance abuse is also a process the hampers wound healing. The rehabilitation process is delayed by substance abuse (Goodman, & Fuller, 2011). Substance abuse affects the immune system of the body. As, the immune system is hampered the process of healing is also reduces.


Diabetes:
The wounds are very difficult to be treated in the disease of diabetes. The circulation of the blood of affected in diabetes. The homeless people like Jones, face many issues including inadequate amount of nutrition intake. The poorly controlled diabetes results in loss of sensation in the nerves. The sensation of the damaged nerve cannot be felt by the diabetes patient (Guo & DiPietro, 2010).

Problem

Intervention

Rationale

Evaluation

  1. Location of Wound

Perineum: requires cleaning every day with specific contact precautions.

The cleaning of the perineum is very important. The wound of the patient requires regular cleaning, as the position of the wound can be very uncomfortable for the patient (Sharma, & Parashar, 2012).

With appropriate cleaning of the location of wound, the wound will start healing.

  1. Activities of Daily Living

Intervention will focus on increasing the ability of the patient to complete daily activities. It will encourage patient to take regular walks and adhere to medication.

Mobility of the patient is very important to carry out daily activities without support of anyone.

The effectiveness of the intervention will be evaluated with movement of the patients and his ability to move easily.

  1. Reduced Mobility

Mobility of the patient is reduced due to wound in perineum. The patient may have problem in making regular and normal movements. Thus, nursing

Mobility of the patient is very important for carrying out daily activities. Mobility will help patient to complete daily activities (Sharma, & Parashar, 2012)

Accessing the color, texture and moisture of the skin to understand the healing process.

  1. Pain

The management of pain is very important, as the wounds are very painful. Pain management will be done through warm therapy and applying cold gel pads.

Warm therapy enhances vascular circulation and reduces perennial discomfort and pain.

The cooling of the perineum reduces the pain and also intensity of the pain (Mohamed, & El-Nagger, 2012).

  1. Referral Needs

Patient should be encouraged to contact doctor regularly.

It is important to evaluate the healing process to avoid any chance of further infection

The process of healing is evaluated by the physician.

  1. Education

Educating the patient is done through providing appropriate knowledge to the patient about self management of wound.

Self management of wound is important for diminishing chances of increased infection.

By evaluating the healing condition of the wound, self management and education effectiveness can be evaluated.

References

Boucher, H., Miller, L. G., & Razonable, R. R. (2010). Serious infections caused by methicillin-resistant Staphylococcus aureus. Clinical Infectious Diseases, 51(Supplement 2), S183-S197.

Branger, C., Gardye, C., Galdbart, J. O., Deschamps, C., & Lambert, N. (2003). Genetic relationship between methicillin-sensitive and methicillin-resistant Staphylococcus aureus strains from France and from international sources: delineation of genomic groups. Journal of clinical microbiology,41(7), 2946-2951.

Cartlidge-Gann, L. (2008). Consider the whole patient, not just the hole: healing a wound cavity by secondary intention. Wound Practice & Research: Journal of the Australian Wound Management Association, 16(4), 176.

Coia, J. E., Duckworth, G. J., Edwards, D. I., Farrington, M., Fry, C., Humphreys, H., ... & Joint Working Party of the British Society of Antimicrobial Chemotherapy. (2006). Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. Journal of hospital infection, 63, S1-S44.

Clark, R. (Ed.). (2013). The molecular and cellular biology of wound repair. Springer Science & Business Media.

Davies, J., & Davies, D. (2010). Origins and evolution of antibiotic resistance. Microbiology and Molecular Biology Reviews, 74(3), 417-433.

Dowsett, C., & Newton, H. (2005). Wound bed preparation: TIME in practice.WOUNDS UK, 1(3), 58.

Doughty, D. B., & Sparks-Defriese, B. (2007). Wound-healing physiology.Acute and chronic wounds. Current management concepts. 3rd ed. St. Louis: Mosby, 56-81.

Goodman, C. C., & Fuller, K. S. (2011). Pathology for the physical therapist assistant. Elsevier Health Sciences.

Guideline for the Management of Patients with Methicillin-resistant Staphylococcus aureus (MRSA). (2013). Department for Health and Ageing, Government of South Australia. Retrieved From: https://www.sahealth.sa.gov.au/wps/wcm/connect/bd32928042372b299e5bfeef0dac2aff/Clinical+Guideline_MRSA_April2014.pdf?MOD=AJPERES

Guo, S. A., & DiPietro, L. A. (2010). Factors affecting wound healing.Journal of dental research, 89(3), 219-229.

Juraja, M. J. (2007). The Missing Link in the Chain–The Infection Control Link Nurse (ICLN). American Journal of Infection Control, 35(5), E110-E111.

Lansdown, A. (2006). Silver in health care: antimicrobial effects and safety in use. In Biofunctional textiles and the skin (Vol. 33, pp. 17-34). Karger Publishers.

Mehta, Y., Gupta, A., Todi, S., Myatra, S. N., Samaddar, D. P., Patil, V., ... & Ramasubban, S. (2014). Guidelines for prevention of hospital acquired infections. Indian journal of critical care medicine, 18(3), 149.

Mohamed, H. A. E., & El-Nagger, N. S. (2012). Effect of self perineal care instructions on episiotomy pain and wound healing of postpartum women. J Am Sci, 8(6), 640-50.

Pray, L. (2008). Antibiotic resistance, mutation rates and MRSA. Nature Education, 1(1), 30.

Rayner, R. (2006). Effects of cigarette smoking on cutaneous wound healing.Primary Intention: The Australian Journal of Wound Management, 14(3), 100.

Sharma, R. K., & Parashar, A. (2012). The management of perineal wounds.Indian J Plast Surg, 45(2), 352-63.

Siegel, J. D., Rhinehart, E., Jackson, M., & Chiarello, L. (2007). 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. American journal of infection control, 35(10), S65-S164.  

Tewhey, R., Cannavino, C. R., Leake, J. A., Bansal, V., Topol, E. J., Torkamani, A., ... & Schork, N. J. (2012). Genetic structure of community acquired methicillin-resistant Staphylococcus aureus USA300. BMC genomics, 13(1), 1.

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