ICP eyewitness reports one of four fatal cases

Not nosocomial — that was clear’

Struck by the apparent lack of traditional risk factors and the severity of the patient’s illness, an infection control professional reported one of the landmark cases of fatal community-acquired methicillin-resistant Staphylococcus aureus.

The unusual nature of the case drew the interest of Kathy LeDell, RN, MPH, an ICP at Children’s Hospital and Clinics in Minneapolis. "I noticed [the patient] was in the pediatric intensive care unit, and truly, I was just curious," she tells Hospital Infection Control. "It was not nosocomial — that was clear. This girl was so very, very sick."

LeDell checked to see if the patient was on her list of chronically ventilated children who go in and out of the hospital and may be intermittently colonized or infected with MRSA. "I wondered if she might be one of those kids, but she wasn’t on our MRSA list that we keep," she says. "She was a healthy normal girl by all appearances, so this was just very unusual."

Because LeDell also works as a clinical specialist in the infection control program at the Minnesota Department of Health in Minneapolis, she was in a good position to alert public health authorities about a possible case of community-acquired MRSA. "These were children with deaths, but certainly we have had other children who have had serious illness but didn’t die," she says. "Most of the [community-acquired] MRSA infections are not serious — like cellulitis and soft tissue. But it is obviously concerning that it is out in the general population and some of these people seem to be having serious infections with it."

Heightened awareness of the cases has probably contributed to increased culturing of suspect cases at the hospital by emergency room physicians, she notes. "If you are starting to see this in your ER — these kids coming in — that is something the ER physicians need to be aware of," LeDell says. "They need to be aware of the patterns in their community, because that obviously affects treatment choices before you have culture results. It may also affect how much culturing you do. That is something the ICP can educate the ER staff about."

ICPs who want to heighten surveillance for such cases can review hospital antibiograms and drug susceptibility patterns, she notes, adding that educating staff and the public about the community cases also will be important. "Obviously, MRSA has been around a long time, but this issue of community-acquired is new, and I think nursing and other staff are very interested in it," she notes. "It probably raises more questions than it answers at this point."

Workers should use standard precautions

Concerned health care workers are being advised that the pathogen is not thought to be more virulent than other staph strains, and the standard infection control measures used for MRSA in the hospital — including hand washing and glove use for patient contacts — would prevent nosocomial transmission of the community strains. "Obviously, a death like that is very upsetting to the staff," she says. "To have that happen to a normal healthy girl so suddenly — that would upset them no matter what the cause was. We told them that the contact precautions they were taking should be effective in preventing them from inoculating themselves."

Indeed, a secondary concern to the public health implications of the cases — particularly if community-acquired MRSA becomes more common — is whether health care workers can still be reassured that their exposures to MRSA in the hospital pose no threat to their families. "It is a concern for all of us," says Susan Shea, RN, CIC, president of the Minnesota State chapter of the Association for Professionals in Infection Control and Epidemiology. "We have often have told people that there isn’t a concern — if you are an employee and you become [MRSA] colonized — about taking it home to your family. Because a person who is not immune-suppressed, has a normal healthy immune system, should not have a problem with it. This is putting a little different light on things."