Infections caused by methicillin resistant Staphylococcus aureus (MRSA) have long been a problem in hospitals and nursing homes.  Over the past decade, MRSA has also emerged as a cause of skin and soft tissue infections in the community.1 Not surprisingly, this organism is now being increasingly recognized as a cause of infections in residents of jails and prisons.2,3,4 This article summarizes basic concepts of MRSA diagnosis and management and reviews recent experiences with MRSA in the correctional environment. 

Staphylococcus aureus (SA)
Staphylococcus aureus (SA) is a bacterium commonly found on the skin or in the nose of healthy individuals.  Although it is often a colonizer causing no disease, it can be responsible for minor to life-threatening infections of the skin, bone, blood, heart valves, and lungs.  SA is easily spread by contact with the skin of a person infected or colonized with the bacteria. SA can also be acquired from inanimate objects that have been in contact with a person carrying the organism.  

Methicillin resistant Staphylococcus aureus (MRSA)
Penicillin resistance in SA is due to the production of beta lactamase, an enzyme that breaks down penicillin's beta lactam ring and renders the drug inactive.  Within a few years of the first clinical use of penicillin in the 1940s, resistance due to beta lactamases was identified. Within a year of the introduction of the semisynthetic, beta lactamase-stable, penicillin methicillin in 1960, MRSA strains were identified. By the 1990s, over half of SA isolated in some hospitals were MRSA.  Nursing homes and other long-term care facilities have been identified as reservoirs. Risk factors for infection with MRSA include prolonged hospitalization, having been in an intensive care unit, contact with other patients who have MRSA, having had surgery or another invasive procedure, injection drug use, and underlying illnesses such as diabetes. 

Many microorganisms that develop high-level resistance pay a competitive price to carry that antibiotic resistance and are less fit.  However, MRSA appears to be as virulent in its resistant form as it is in its wild type.  Most MRSA infections are minor infections of the skin that take the form of pustules, furuncles or boils.  Generally, these conditions are mild and self-limited.  It is not always necessary to treat every infection aggressively. 

Methicillin resistant strains are resistant to all beta lactam antibiotics, including penicillins and cephalosporins.  In addition, MRSA strains often carry plasmids that lead to resistance to multiple other antibiotics.  Many MRSA strains are susceptible to trimethoprim-sulfamethoxazole and rifampin. Virtually all SA are fully susceptible to vancomycin. However, the first clinical isolate of SA with reduced susceptibility to vancomycin was reported from Japan in 1996.5 The first documented case of infection caused by vancomycin-resistant S. aureus (VRSA) (vancomycin MIC >32 µg/mL) in a patient in the United States was reported in 2002.6  

Is it just a spider bite?
In the correctional setting, there has been significant amount of misinformation on the "inmate grapevine" that attributes these otherwise unremarkable lesions to arachnid bites.  In reality, spiders rarely bite people, and most of the bites are inconsequential. Most spiders only bite when provoked such as when they are trapped in clothing or in a shoe. Spider bites characteristically occur at areas where the spider might settle in the clothing, such as the waistband. It is unusual for a spider to bite multiple times.  

The brown recluse spider, or Loxosceles reclusa, in particular, has been blamed for lesions among the incarcerated. Found in the Midwest and Southeast, this arachnid prefers isolated areas and is rather shy and timid. It hibernates during the winter, so bites, which are generally painless, occur between March and October. Following a bite, the skin may exhibit a urticarial lesion (hive), a papule, or a pustule. In severe reactions, patients may develop systemic signs including rash, fever, headache, and other flu-like symptoms. Only a small proportion of bites become necrotic, and the progression follows a characteristic pattern termed the "red, white, and blue" sign: a central blister with purple-gray discoloration (in Caucasians), surrounded by a white ring of blanched skin and a much larger halo of red. If skin breakdown occurs, the site becomes painful, usually progressing to a black eschar and may be slow to heal.

The misinterpretation of minor skin lesions as spider bites has ironically led to actions that potentially increase health risks for many inmates. The use of chemicals to eradicate the falsely accused spiders only serves to eliminate an ally in the war against mosquitoes, which are known to carry illnesses such as West Nile virus. 

Recent MRSA outbreaks
Outbreaks of MRSA infections are being increasingly recognized in jails and prisons throughout the country.2,3,4  Factors that may have contributed to the problem include: limited access to soap or bathing, mental illness among prisoners leading to poor hygiene,  inadequate laundry procedures, co-payments for medical care which may limit access to medical care, infrequent collection of wound cultures, and the misperception that lesions were due to spider bites. 

Georgia: In 2001 and 2002, the Georgia Division of Public Health, the Georgia Department of Corrections, and local health departments investigated outbreaks of MRSA skin infections in three correctional facilities.  Risk factors identified included prolonged incarceration, previous antimicrobial use, self-draining of boils, skin laceration (intentional or accidental), washing clothes by hand, and sharing soap.  Beta lactam antibiotics were not uncommonly used, even after the identification of MRSA.  A number of measures were implemented, with limited success. These included wide spread screening for skin disease, implementation of standardized antimicrobial treatment recommendations, changes in laundry practices, inmate education, the use of chlorhexidine containing soaps, and the use of alcohol-based hand rubs. 

Los Angeles: In 2002, the Los Angeles (L.A.) County jail experienced an increase in reports of spider bites. In response, a protocol was initiated that called for culturing all suspected spider bite lesions. Between January of 2002 and June of 2003, over 1,600 MRSA skin infections were identified. In collaboration with the L.A. County Department of Health Services, the jail recommended changes to include enhanced skin lesion surveillance, standardized treatment protocols including empiric treatment with non-beta-lactam antimicrobials for all wound infections, inmate hygiene education, environmental cleaning, and more frequent laundry changes.

Texas:  In 1996, the Texas Department of Criminal Justice (TDCJ) implemented a comprehensive set of treatment and prevention guidelines for MRSA skin infections that included 1) surveillance, 2) hygiene education for inmates, 3) access to proper wound care, 4) standardized antimicrobial therapy based on drug susceptibility data (including directly observed therapy), 5) early treatment of skin disease, and 6) eradication of MRSA from asymptomatic carriers who have recurrent MRSA infections. Since 1998, TDCJ has required culturing of all draining skin lesions and reporting of results to the TDCJ Office of Preventive Medicine. The proportion of SA infections that were methicillin-resistant increased from 24% (864 of 3,520) in 1998 to 66% (5,684 of 8,633) in 2002. Implementation of guidelines and a continued multidisciplinary approach to MRSA infections has not led to substantial decreases in the incidence of MRSA.

Mississippi:  An evaluation of MRSA cases at a state prison in Mississippi revealed that 19 of 21 (90%) of infected inmates with wound dressings changed their dressings themselves. Fifteen (33%) of infected inmates reported helping or being helped by other inmates with wound care or dressing changes. Twenty-six (58%) reported lancing their own boils or other inmates' boils with fingernails or tweezers; forty (89%) shared personal items (e.g., linen, pillows, clothing, and tweezers) that potentially were contaminated by a wound. 
 
Treatment of MRSA infections 
Some correctional systems have developed guidelines for the management of  MRSA. In July 2003, the federal Bureau of Prisons issued guidelines to prevent and control MRSA in correctional facilities7. This document recommends the reporting and tracking of patients with MRSA and offers a convenient form to do so.  In addition, a useful patient education handout can be found at the end of the document.

Facilities detecting a substantial number of MRSA infections should implement improved hygiene, infection-control, and treatment practices. Skin lesions should be cultured to determine the infecting organism. Drainage of abscesses is important to facilitate cure. Empiric antibiotic selection should be made with MRSA in mind. Treatment should be adjusted as needed based upon the infecting organism's antibiotic susceptibility pattern. 

Trimethoprim-sulfamethoxazole (Bactrim, Septra) in a dose of one double-strength tablet twice daily is usually effective in patients who have MRSA. Some clinicians also add rifampin in a dose of 600 mg once daily. Due to the rapid development of resistance, rifampin should not usually be used alone to treat infections due to SA. For more serious infections, intravenous vancomycin or oral linezolid may be used. A new antibiotic, daptomycin, (Cubicin™) has recently been approved for treatment of skin infections due to SA.  Daptomycin is given parenterally, and has a spectrum of activity that includes virtually all Gram-positive organisms including E. faecalis, E. faecium (including VRE) and SA including MRSA. Daptomycin should not be used for pneumonia due to higher failure in clinical trials, and should not be relied upon for CNS or bone infections due to poor penetration of these tissues. 

Clinicians are reminded that oral vancomycin is non-absorbable and is, therefore, not useful in the treatment of skin and soft tissue infections due to SA. 

Eradication of nasal carriage
SA and MRSA commonly inhabit the anterior nares of otherwise healthy asymptomatic individuals.  Routine eradication of this carriage is neither efficacious nor recommended. In some cases of recurrent active disease, clearance of the organism from the nose can be beneficial.  Mupirocin (Bactroban®) ointment, applied to both anterior nares bid for 5-7 days, is commonly used for this purpose. 
 

Education and Infection Control
Inmates should be educated about personal hygiene, and advised to avoid touching other persons' wounds or wound drainage.  Inmates should be provided access to soap, showers, and sinks. Clinical staff that provides wound care should follow Standard Precautions. Infection control measures can never be overemphasized, as even in the hospital setting many healthcare professionals neglect hand washing. The restrooms in many hospitals and public settings are poorly designed, leading people to re-contaminate their hands immediately after washing them.  

In an effort to improve hand hygiene, the use of alcohol-containing antiseptic scrubs is increasingly being encouraged. However, security concerns may lead to these particular disinfectants not being universally embraced in the correctional setting.  Surfaces that are used by multiple people should be routinely decontaminated. Laundry should be washed in hot water for at least 25 minutes to be sure that most bacteria have been exterminated.  Custody staff should be educated to refer inmates who have even minor-appearing skin infections so that an appropriate evaluation can be performed. 

The involvement of experts in infection control and infectious diseases can be useful in both managing individual patients and establishing protocols specific to the unique needs of each facility. 

Correctional facilities experiencing outbreaks of MRSA should seek assistance from their local and state health departments. MRSA outbreaks can be reported to CDC (telephone [800] 893-0485) through state departments of corrections and state health departments.  Preventing MRSA disease in inmates might be an important measure for preventing MRSA in the community outside the correctional facility. Additional information about MRSA is available at http://www.cdc.gov/ncidod/hip/aresist/mrsa.htm  

In conclusion, the recent experience with MRSA in jails and prisons reminds us that antibiotic-resistant organisms will continue to be a significant problem in this country. Lessons learned from the MRSA experience may also be applicable to other infections to come.  Correctional healthcare providers' responsibility to public health cannot be underestimated. It is important to strengthen our relationships with outside public health agencies as we strive to contain this growing threat to the health of those patients entrusted to our care. 

Disclosures: *Nothing to disclose.
**Nothing to disclose.
References:
1. CDC. Methicillin-resistant Staphylococcus Aureus Infections Among Competitive Sports Participants---Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000-2003. MMWR 2003;52:793--5.
2. CDC. Methicillin-Resistant Staphylococcus Aureus Skin or Soft Tissue Infections in a State Prison---Mississippi, 2000. MMWR 2001;50:919--22.
3. CDC. Outbreaks of Community-Associated Methicillin-Resistant Staphylococcus Aureus Skin Infections---Los Angeles County, California, 2002--2003. MMWR 2003;52:88.
4. CDC: Methicillin-Resistant Staphylocccus Aureaus Infections in Correctional Facilities---Georgia, California, and Texas, 2001-2003. MMWR 2003; 52(992-996).
5. Hiramatsu K, Hanaki H, Ino T, Yabuta K, Oguri T, Tenover FC. Methicillin-Resistant Staphylococcus Aureus Clinical Strain with Reduced Vancomycin Susceptibility. J Antimicrob Chemother 1997;40:135--6.
6. CDC. Staphylococcus Aureus Resistant to Vancomycin --- United States, 2002. MMWR 2002;  51(26); 565-567      
7. Federal Bureau of Prisons. Clinical Practice Guidelines for the Management of Methicillin-Resistant Staphylococcus Aureus (MRSA) Infections (October 2003). 
http://www.nicic.org/Resources/BOPMedicalGuidelines.aspx

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