There’s a new bug in town: Community associated methicillin-resistant Staphylococcus aureus
—or CA-MRSA—is the newest strain of bacteria that causes staph infection—and that spreads in non-hospital settings among people who are otherwise healthy.
Although MRSA infections dropped in the U.S. from 2005–2012, the rate of decline has since slowed, according to the U.S. Centers for Disease Control and Prevention.
CA-MRSA infections initially manifest as a small, red bump patients often mistake for a bug bite or a pimple, but this bump can quickly become a painful boil or abscess.
Statistics suggest why massage professionals need to pay attention: In 2005, 94,360 cases of MRSA infections occurred in the U.S. Fifteen percent were acquired through community (non-hospital) infection.
Given the intimate nature of massage treatments, it’s essential to know who is likely to carry the MRSA infection, how it is transmitted and what treatments are available.
Increased Infections
“The skin and soft tissue are the most vulnerable to methicillin-resistant Staphylococcus aureus infections,” said C. Buddy Creech, MD, MPH, of Vanderbilt University Medical Center and Children’s Hospital in Nashville, Tennessee. “Yet, MRSA can also cause bone and joint infections, pneumonia and bloodstream infections.”
In the past, staph infections, such as MRSA, occurred mainly in hospitals, long-term care facilities and health-care settings, such as dialysis centers.
However, the newest strain of MRSA—also known as USA300—is more often than not “a personal hygiene and a (skin-to-skin) contact issue,” said Barry Kreiswirth, PhD, a research scientist who is director of the Public Health Research Institute Center in Newark, New Jersey.
The Centers for Disease Control and Prevention (CDC) defines MRSA as a type of bacterium resistant to a class of antibiotics called beta lactams, including methicillin, and common antibiotics, such as oxacillin, penicillin, amoxicillin and cephalosporins.
Kreiswirth and four medical experts who were interviewed for this story and specialize in bacterial and MRSA research emphasize this staph infection is preventable and treatable. They offer suggestions to help massage therapists protect themselves and their clients.
“MRSA was first known to me in 1980 when I was still in [medical school] training,” recalls Terry Clyburn, MD, an orthopaedic surgeon and, at the time this article was written, spokesperson for the American Academy of Orthopaedic Surgeons in Bellaire, Texas. “At that time, the antibiotic of choice for MRSA—vancomycin—was only available through the Centers for Disease Control and Prevention.
“It was known that this organism was clearly a hospital-associated infection and that patients in the intensive-care units were at highest risk of contracting the bacterial infection,” he adds.
Today, health professionals are increasingly reporting MRSA infections among populations that have not been hospitalized or had medical procedures. In fact, MRSA acquired in the community is a different genetic strain of staph than hospital-acquired MRSA.
Simple Steps
MRSA can live on inanimate surfaces for several days, unless they are sanitized with a disinfectant cleaner or a diluted bleach solution.
John Tudor, a microbiology professor at St. Joseph’s University in Philadelphia, Pennsylvania, said in settings where there is direct skin-to-skin contact or frequent contact of bare skin to surfaces, such as massage offices, practitioners should post and follow clear guidelines for hand washing, cleaning and disinfecting surfaces. “[But] keeping abrasions clean and covered is the best protection,” Tudor said.
Kreiswirth adds, along with the many antibacterial products on the market, soap and water work well too. “Bacteria won’t grow if [the surface] is wiped down and clean.”
He continues, “One of the things we have learned about MRSA is that it is not just exposure we’re talking about. The longer you give the bacteria the opportunity to rest on your skin, the greater [the chance] of spreading.”
Frequent hand washing, especially after touching areas where staph is likely to live, is a first step in infection control, Kreiswirth said.
Rachel Orscheln, MD, an infectious disease specialist and pediatrician at Washington University School of Medicine in St. Louis, Missouri, said massage therapists should know “how to recognize when someone has an infection that could contain MRSA bacteria and could be transmissible.” But even before beginning a massage, the therapist should be aware of clients who have a history of skin infections.
“If the massage therapist sees a client with a boil,” she should know prompt medical care is necessary and suggest the client see a physician, she adds.
Orscheln advises massage therapists to pay careful attention to their own skin and to notice new sores that begin to redden, swell or become painful. Kreiswirth offered a simple reminder: “Practitioners should use a commonsense approach to their personal hygiene,” noting clean towels, fresh soap and clean clothing are often all that is needed. While not always practical, “The best thing anyone [practitinore or client] can do is to shower before and after a massge,” he said.
10 Steps to Help Prevent MRSA in Your Practice
1. Wash hands with warm soap and water for at least 20 seconds, immediately before and after each session and after changing linens and towels. Have liquid soap in dispensers available at all sinks.
2. Change linens and towels following each massage session. When changing linens, fold them away from the body to avoid contaminating clothes.
3. Wash linens in hot water with detergent and bleach.
4. Keep abrasions clean and covered with an antiseptic cream and a bandage.
5. Ask clients if they currently have any broken skin, open wounds or boils; don’t be shy about rescheduling the appointment if a client has a skin infection.
6. When using bleach, know the proportions to use for human use versus surface objects. Disinfect surfaces with a disinfectant cleaner or a bleach solution.
7. Avoid sharing towels, washcloths and razors.
8. If you work with others, post and follow clear guidelines for hand washing, cleaning and disinfecting surfaces.
9. Learn about all clients and their lifestyles: It might be appropriate to recommend those in high-risk populations take a shower before coming in for a massage session.
10. If you do develop a staph infection and are prescribed an antibiotic, follow the directions on the bottle carefully. Do not stop taking the antibiotic until completing the dosage, even if the symptoms have disappeared.
Susceptibility
Scientists still aren’t sure why some people are more susceptible to developing MRSA infections.
Tudor explained while most people come into contact with staph every day, “our immune systems are sufficient to prevent infection. As with all pathogens, susceptibility to contracting infectious disease varies from one person to the next.”
Even if the client does not have an active infection, he or she can still be a carrier of CA-MRSA, which means the person can pass the staph germ to others, said Orscheln, who has co-authored several research papers on CA-MRSA.
In fact, about one-third of us carry benign Staphylococcus aureus in our noses or on our skin. Those who have staph on their noses or skin but do not have an infection are said to be “colonized” with the staph germ. But only about 1 percent carries staph that is actually infected. Besides the nose and skin, staph also lives in the armpits, groin and vagina, as well as in throats and mucous membranes.
The precise mechanisms by which Staphylococcus aureus colonizes the nose and skin are still unknown, but we do know bacteria need to penetrate skin in order to grow.
Bacteria “require a break in the skin,” Tudor explained. In general, people with openings in their skin are “more susceptible to staph setting up an infection.”
Creech, who with his research colleagues is studying the molecular epidemiology of CA-MRSA, acknowledges a person who has an active infection, such as an uncovered abscess, “is more likely to share the germ with others.”
Some types of diagnoses and some conditions are more susceptible to staph infection, whether in hospitals and health facilities, or in the community.
“Knee replacements may be a slightly higher risk of infection in general,” explained Clyburn. And patients who have immune-deficiency conditions, such as rheumatoid arthritis, or have had multiple operations or a transplant, or who may be taking prednisone are also at risk of MRSA infection.
Athletes, 10-year-olds, high school teams, and military personnel are other at-risk groups, adds Kreiswirth, who has helped conduct surveillance and prevalence research on CA-MRSA in collaboration with the CDC and National Institutes of Health.
These populations have one thing in common: They all work or play in environments that often are warm, moist and salty—the kind of atmosphere in which Staphylococcus aureus thrives.
Antibiotic Use
Clyburn calls CA-MRSA “an inherently different organism from HA-MRSA.” He notes physicians need to pay particular attention to prescribing the appropriate antibiotic for each strain of MRSA.
“I have seen cases of infection occurring in the skin of young people who had not been in a hospital, which the primary physician treated with an ineffective antibiotic,” Clyburn said. “The infection worsened, leading to hospitalization, surgical drainage and treatment with an antibiotic appropriate for MRSA.”
However, the inappropriate use of antibiotics has also created resistance in some bacteria, making some germs difficult to kill and even eliminating beneficial ones.
The increase in the cases of MRSA is partially “the result of an overuse of antibiotics,” Creech said. “The challenge now is that the number of choices of antibiotics are much more limited. Therefore, we have very difficult choices to make, depending on the person’s health and the nature of the infection.”
Yet despite its resistance, CA-MRSA is “highly treatable with other antibiotics besides penicillin,” Orscheln said.
Unlike HA-MRSA, “which is typically resistant to many classes of antimicrobials,” she adds, “CA-MRSA typically has retained susceptibility [or is not resistant] to a variety of antimicrobials, including tetracylines (tetracycline, doxycycline and minocycline, clindamycin and linezolid).
What’s more, many physicians are now treating infected abscesses by draining them. Compare that to 10 years ago, Kreiswirth said, when physicians would treat a boil with penicillin. “Draining the abscess does work and allows the physician to treat the infection without penicillin drugs,” he said.
Bacteria Among Us
When seeing patients in his practice, Creech asks them if anyone else in the family has had skin infections or abscesses. If so, he “assumes they have MRSA,” until lab cultures prove otherwise. But even for those who haven’t been exposed, “it’s a good reminder to always wash our hands.” He advises massage practitioners to consider every person they come in contact with as potentially harboring infection.
“One of the things we have to make certain we understand is that MRSA is not a ‘Scarlet M’ on the chest,” he adds. “It’s a strain of staph that is resistant to our most commonly used antibiotics that can cause serious skin infections. Therefore, it behooves us to take this opportunity to understand staph in a general sense.”
One thing is certain: As bacteria continue to modify their biological structures in response to a changing environment, we need to be even more willing to incorporate behavioral change in our daily routines.
“Today it’s MRSA,” Creech said. “Tomorrow it might be a completely different organism.”
“The co-evolution between man and bacteria will continue,” Kreiswirth offered, “and we need to keep them in their place.”
Massage therapists are in a perfect position to help prevent MRSA from spreading and to keep future bacterial infections in check.
About the Author:
Chris Cunningham has written many articles for MASSAGE Magazine. She also publishes media and marketing materials for private clients and magazine feature stories for trade and general interest magazines, including business, higher education and medical publications. Prior to her freelance career, Cunningham worked for 20 years in nursing home and hospital administration and management, in which she holds a master’s degree.