Scenario for Think Break

Sean B. Sarigumba September 2, 2020

Level 2 Section A Microbiology and Parasitology

Case Study:

A patient assigned for morning care has an open wound on her left lower leg. The wound is draining,
and when last cultured, the microorganism Methicillin-Resistant Staphylococcus Aureus (MRSA) was
identified. In preparation for bed making, the hands of the nurse were washed. Clean linen and a bag for
soiled linen were gathered from the linen room and placed on the patient's clean bedside stand. To
remove the soiled linen from the bed, the following procedure was followed: 

1. Hands washed

 2. Gloves worn 

3. Each side of the soiled linen ends folded towards the middle of the bed

 4. Soiled linen held away from the nurse's clean uniform

 5. Soiled linen placed in the linen bag for later discard

 6. Protective gloves removed 

7. Hands washed 

Source: www.slideshare.net, 2016 

Guide Question: In relation to MRSA pathogenicity and nutritional requirement, address how the nurse
considered these in patient care.

MRSA Pathogenicity and Nutritional Requirements:

 Staphylococcus aureus is a versatile pathogen capable of causing a wide range of human diseases.
However, the role of different virulence factors in the development of staphylococcal infections remains
incompletely understood. Some clonal types are well equipped to cause disease globally, whereas
others are facile at causing disease among community members. The armamentarium of S. aureus'
virulence factors is extensive, with both structural and secreted products playing a role in the
pathogenesis of infection.
Figure 1. Pathogenic factors of Staphylococcus aureus, with structural and secreted products both
playing roles as virulence factors. A. Surface, and secreted proteins. B and C, Cross-sections of the cell
envelope.

To provide further context on the bacteria regarding this case study, Staphylococcus aureus is a Gram-
positive, non-spore-forming, nonmotile, cocci bacterium that colonizes in yellow clusters. This
microorganism is a facultative anaerobe and is naturally present in human beings' flora, especially in the
regions of the anterior nares. In fact, it is the most common type of staphylococci because of its ability
to continuously evade the immune system and a wide variety of antibiotics. Specifically, in this case
study, the methicillin-resistant strain of  Staphylococcus aureus is responsible for causing mild to severe
skin infections if not treated immediately.

Transmission

Since S. aureus is a part of the natural flora in mouths and noses of humans, especially in healthcare
workers within clinical settings, the spread of these microorganisms can be difficult to prevent. Due to
the bacteria having nonmotile properties, S. aureus is most commonly spread through human-to-human
contact or contaminated surfaces/foods.

Infectious colonization, dose, and incubation

S. aureus naturally colonizes in many parts of the body, such as the nose, mouth, mammary glands, hair,
upper respiratory tract, and more. In most cases, S. aureus colonizes these parts of the body harmlessly.
These bacteria can survive in a wide range of temperatures ranging from 15-45 degrees Celsius and can
also colonize in NaCl concentrations up to 15%. When ingested, the infectious dose of S. aureus is
greater than 100,000 organisms, and the incubation period ranges from 30 minutes to 8 hours. 

Epidemiology
S. aureus is distributed worldwide and is most often found in hospitals and nursing homes, but
community settings are becoming increasingly contaminated. Scientists typically distinguish between
CA-MRSA and HA-MRSA when studying epidemiology. A surgeon in the 1890's first isolated
staphylococcus aureus. MRSA's first strain was observed in 1961, and now approximately 35% of
hospital strains of S. aureus are methicillin resistant.

Adherence

S. aureus expresses specific surface proteins that are necessary for binding throughout the body. These
surface proteins typically promote attachment to laminin and fibronectin. Most strains also express a
clumping factor, coagulase, that promotes attachment to blood clots and traumatized tissue. Fibronectin
and fibrinogen-binding proteins are also produced by S. aureus as virulence factors. Mutations of these
proteins that have been studied drastically decrease the bacteria's virulence. Adhesins that bind to
collagen are significant in infections that cause osteomyelitis. Once the bacteria have adhered, they can
secrete a biofilm that makes them difficult to eradicate.

Invasion

Invasions help to promote bacterial spread within the tissues of the body. Alpha toxin is the most
characterized and potent membrane-damaging toxin secreted by S. aureus. It is expressed initially as a
monomer that binds to the surface of susceptible cells before becoming oligomerized into a heptameric
ring that causes a pore in the membrane of the attacked cell, which causes the contents of the cell to
leak out. Platelets and monocytes are especially susceptible to this toxin. ß-toxin is a sphingomyelinase
toxin that damages lipid membranes that are rich in sphingomyelin. It is not often expressed in human
isolated strains of the bacteria.

A mere 2% of S. aureus isolates express leukocidin, a multi-component protein that acts to severely
damage cell membranes, but 90% of S. aureus strains isolated from severe dermonecrotic lesions are
found to express this toxin. This correlation suggests that the toxin is a large component of necrotizing
skin infections. Leukocidin forms a hetero-oligomeric transmembrane pore made from four LukF and
four LukS subunits. This toxin is hemolytic but not as hemolytic as alpha-toxin.

S. aureus also produces a host of proteases, lipases, and DNase, and FAME (fatty acid modifying
enzyme). FAME may be necessary for virulence in abscesses, where it could prolong bacterial survival by
modifying anti-bacterial lipids in the cell.

Avoidance

S. aureus produces a microcapsule composed of surface polysaccharide that can only be detected by
electron microscopy to avoid the immune system. Strains of the bacteria isolated from infections have
been found to produce this capsule in high amounts. This capsule helps the bacteria evade phagocytosis
in the absence of complement. Protein A is an Fc receptor on the pathogen's surface that specifically
binds the IgG antibody in the wrong orientation. This incorrect orientation of the antibody disrupts the
bacteria's opsonization and phagocytosis, allowing it to evade the immune system. Leukocidin also helps
avoid the immune system, as acts specifically on phagocytic cells called polymorphonuclear leukocytes.

Toxins
This bacterium produces several toxins, such as invasion toxins. S. aureus also releases other exotoxins
and enterotoxins. Exfoliatoxin comes in two distinct forms (ETA and ETB) and causes scalded skin
syndrome in infants. These bacteria secrete two different toxins that are considered to have
"Superantigen activity," enterotoxins, and Toxic Shock Syndrome Toxin (TSST-1). There are six types of
enterotoxins (SE-A, B, C, D, E, and G), which cause food poisoning in the host. Enterotoxins B and C are
also responsible for 50% of non-menstrual related cases of TSS.

Resistance

Through many generations, Staphylococcus aureus has evolved an extensive repertoire of antibiotic
resistance. The most common resistance is that of methicillin like antimicrobials. These antimicrobials
usually hinder the synthesis of the bacteria's cell wall. The mecA resistance gene in the bacteria's DNA
keeps these β-lactam antibiotics from inhibiting the bacteria's transpeptidase enzymes critical for cell
wall construction. This gene is carried on a mobile Staphylococcal cassette chromosome (SCC). The SCC
carries various genes that lend themselves to antibiotic resistance and are usually transmitted vertically
and horizontally across S. aureus strains.

The emergence of methicillin-resistant 

Staphylococcus aureus (MRSA) strains as potentially lethal pathogens is a continuing cause for public
health concern worldwide. Understanding the various virulence mechanisms used by these antibiotic-
resistant bacterial pathogens is crucial to help prevent and treat the infections they cause.

Considerations In Nursing Care

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most frequent reasons for hospital and
community-associated infections. Resistance to the entire class of β-lactam antibiotics, such as
methicillin and penicillin, makes MRSA infections difficult to treat. The same holds even more weight for
patients and healthcare workers and staff who come into daily contact with these pathogens, making
them more susceptible to infection. In the case study above, the patient is prone to infection for a
variety of reasons, which include compromised immune systems dues to open areas on their skin due to
their wounds and as nursing staff comes close to provide treatment, it is easy for them to facilitate
cross-contamination should they fail to follow the proper handling procedures

In this regard, it is important to implement infection control through an in-depth understanding of the
chain of infection. It is done for healthcare personnel to be able to come up with methods in supporting
vulnerable patients and prevent the further transmission of infection. Put simply, in order to stop the
infection, the chain of infection must be broken.
 Figure 2. Chain of Infection

In the given case study, the nurse on duty was able to apply and demonstrate the principles regarding
medical asepsis and hygiene and further utilize standard precautions regarding the implementation of
body substance isolation in containing infectious microorganisms at various points in the chain of
infection. Through the implementation of handwashing, the nurse has eliminated the infectious agent
and the mode of transmission. By donning her gloves, she has further removed the portal of entry. By
folding the linens' ends towards the middle of the bed, she contained the reservoir and the potential
modes of transmission for the pathogens. As she held the dirty linens away from her uniform, she broke
the chain of infection by eliminating the mode of transmission and a potential portal of entry.

By discarding the soiled linens in the linen bag for disposal, she then reinforced the elimination of the
reservoir and the mode of transmission, and also by removing her protective gloves afterward, she
eliminated a reservoir and mode of transmission. Lastly, by washing her hands, she removed a possible
portal of entry, reservoir, and transmission mode for the microorganisms in the chain of infection.
In our line of work in the health care sector, safe working practices in hospitals and clinical areas are a
vital necessity in the delivery of healthcare services. By maintaining a clean and safe environment for
our patients, nurses, and healthcare workers are able to provide competent care, and it also reflects the
level of compassion and vigilance that we have towards our patients. It is important that these
conditions are upheld by the hospital staff and management, and proper waste segregation and disposal
must also be implemented not only for the recipients of hospital services but also for the environment.
References:

Contributor, N. (2019, August 01). Skills: Managing MRSA in hospital and in the community. Retrieved
September 02, 2020, from https://www.nursingtimes.net/archive/skills-managing-mrsa-in-hospital-and-
in-the-community-06-03-2007/

Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or
Targeted Multidrug-resistant Organisms (MDROs). (2019, July 29). Retrieved September 02, 2020, from
https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

M;, O. (n.d.). MRSA virulence and spread. Retrieved September 02, 2020, from
https://pubmed.ncbi.nlm.nih.gov/22747834/

Raut, G. (2017, September 12). Chain of infection: First Steps. Retrieved September 02, 2020, from
https://rcni.com/hosted-content/rcn/first-steps/chain-of-infection

Methicillin Resistant Staphylococcus Aureus (MRSA). (n.d.). Retrieved September 02, 2020, from
https://microbewiki.kenyon.edu/index.php/Methicillin_Resistant_Staphylococcus_Aureus_(MRSA)