Kelly on Malpractice

MRSA stands for methicillin-resistant Staphylococcus aureus. The term is used to describe a number of strains of the bacteria, Staphylococcus aureus, that are resistant to a number of antibiotics, including methicillin. What is Staphylococcus aureus? Staphylococcus aureus is a group of bacteria that live on the surface of people’s skin and inside the nose. It is normally harmless: most people who are carrying it are totally unaware that they have it. In fact, it is thought that up to 30% of the general population carries these bacteria in their nose or on their skin.

Problems occur if Staphyloccocus aureus bacteria are able to enter the body through a cut or wound. Most healthy people have strong immune systems and are able to fight off a Staphylococcus aureus infection themselves and have only mild symptoms. However, people with weakened immune systems (for example due to other illnesses) or who have undergone sugery (for example heart surgery or hip replacement) can develop more serious problems. In more vulnerable people, Staphyloccocus aureus bacteria have been known to cause boils, abscesses, impetigo, septic wounds, heart-valve problems and toxic shock syndrome. In extreme cases, it can result in death.

People with weakened immune systems who have been infected with Staphylococcus aureus require treatment with antibiotics to help clear the infection. The concern with MRSA strains of bacteria is that they are resistant to a number of the antibiotics that are normally used to treat Staphylococcus aureus infections. Because MRSA is resistant to a number of different antibiotics, it is harder to treat than non-resistant bacteria. However, MRSA is not resistant to every antibiotic and most strains of MRSA can still be treated with vancomycin, teicoplanin and mupirocin.

For people with weakened immune systems who have become infected with MRSA, the best treatments are with the antibiotics vancomycin or teicoplanin. These two antibiotics are given as injections or through an intravenous drip and so are only given to people in hospital. Certain groups of people are at a higher risk of infection with MRSA. For this reason, some healthy people are screened for MRSA by having a swab of their skin or inside of their nose taken. If these healthy people are found to be carrying MRSA on their skin or in their noses, they are normally treated with an antibiotic cream - mupirocin. This is applied to the affected areas of the body. This is done to reduce the chance of the bacteria entering the body through an open wound and the chance of other people catching MRSA.

MRSA has appeared for three reasons: the widespread use of antibiotics, genetic selection and our dislike of tablets. It is the subject of some “end of the world” books where the theme is the extinction of human life due to a world-wide pandemic infection that is drug resistant. Bacteria are constantly evolving because their genes are constantly changing. The result of this is that some of the bacteria will have more resistance to a certain antibiotic than others. So, when the weaker bacteria encounter that antibiotic, they are killed. But the more resistant ones will take longer to die. If these more resistant bacteria are not killed off, they will survive and multiply. Their “offspring” will have this resistance to the antibiotic and further changes to their genes will mean that some will be even more resistant to the antibiotic.

Over time this combination of bacterial genetic change and our dislike of taking tablets has resulted in strains of Staphylococcus aureus that are resistant to many of today’s antibiotics. Normally these strains are resistant to just one or two antibiotics but, as in the case of MRSA, they can be resistant to more. This is why doctors encourage us to finish the whole course of antibiotics when we are prescribed them. The antibiotic will rapidly kill off the weaker bacteria and we will start to feel better.

Many doctors believe that if we stop taking the antibiotic at this point, the stronger bacteria will survive and could produce more drug-resistant “offspring”. If the next person who is infected also fails to finish the whole course of the antibiotic, then even more resistant bacteria will result. For this reason, it is thought that this can all be avoided if we take the whole course of antibiotics in the first place: by taking all the tablets, all the bacteria (including the more resistant ones) should be killed off and no offspring can be produced.

MRSA is particularly important in hospitals for three reasons: hospitals contain a large number of people with weakened immune systems who could become infected with MRSA and develop unwanted symptoms. Many of the patients in a hospital have an intravenous drip or a catheter that creates a “wound” through which MRSA can enter the body. In some hospitals, people are in close proximity to each other, which increases the chances of MRSA infecting patients. However, in others patients stay in separate rooms which helps to lower this risk. Hospitals offer many opportunities for Staphylococcus aureus bacteria to encounter a wide range of antibiotics and, through genetic change and survival, develop resistance to all of them.

I use to steer away from MRSA cases because the “seeding” process is often part of the risk of obtaining health care services. However, I have changed my antipathy about these cases because I am finding a lack of vigilance and treatment after the patient is likely infected. Most hospitals and practice groups have, or should have, MRSA policies to protect their patients. If the healthcare provider does not adhere to those policies, then patients suffer. The lawsuit emanating from such a tragedy is straight forward. Vancomycin will save a life if treatment is instituted early. I suspect this accounts for why these lawsuits are increasing accross the country.