The Journal for Nurse Practitioners
Volume 6, Issue 6 , Pages 435-441, June 2010

Community-Associated MRSA Infections in Women

  • Allyssa L. Harris

      Affiliations

    • Allyssa L. Harris, PhD, RN, WHNP-BC, is a clinical assistant professor at the William F. Connell School of Nursing at Boston College and a nurse practitioner at Roxbury Comprehensive Community Health Center in Boston, MA.
    • ,
  • Heidi Collins Fantasia

      Affiliations

    • Heidi Collins Fantasia, PhD, RN, WHNP-BC, is a postdoctoral fellow at Boston College and a nurse practitioner for Health Quarters in Beverly, MA.

Article Outline

Abstract 

Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital pathogen, but now its prevalence in the community is increasing. Community-associated MRSA (CA-MRSA) is the causative agent in many outpatient skin and soft tissue infections. Within the women's health population, CA-MRSA infection can result in a variety of genital skin infections, including boils, furuncles, and abscesses. Antibiotic-resistant strains, reinfection, and transmission among close contacts contribute to difficulty in controlling the spread of this pathogen. This article provides an overview of CA-MRSA, its clinical presentation, diagnosis, treatment, and implications for clinical practice in women's healthcare settings.

Keywords:  methicillin-resistant Staphylococcus aureus , MRSA , women's health

 

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Introduction 

Although methicillin-resistant Staphylococcus aureus (MRSA) infections have become relatively common in hospital settings, their prevalence in the community is increasing. Researchers have found that community-associated MRSA (CA-MRSA) prevalence varies by population and geography.1, 2 In one study, researchers found an overall prevalence rate of 59% with a range of 15% to 74% of CA-MRSA in participants who visited emergency departments in 11 major cities in the United States.3 While not commonly associated with women's health, CA-MRSA has been increasingly diagnosed in this population and has been documented in the pediatric population, in pregnant and postpartum women, and in neonatal intensive care units.4, 5 This article provides an overview of CA-MRSA, the clinical presentation of CA-MRSA and its presentation, diagnosis, and treatment, and implications for clinical practice in women's healthcare settings.

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S Aureus and its Characteristics 

The bacterium S aureus is commonly found on the skin and nasal passages of many healthy individuals and causes no untoward events. Unfortunately, virulent strains have emerged that produce toxins responsible for local skin destruction, fever, and a cascade of events that can lead to end-organ failure and death.6 Additionally, antibiotic-resistant strains, referred to methicillin-resistant, have emerged that complicate treatment and control of infections.

S aureus, a gram-positive coccus, is a member of the Micrococcaceae family and is highly adaptable. Although the hands and nose are the most common colonization sites, S aureus can also be found in axillae and the groin. It has been estimated that approximately 25% to 30% of the population are carriers for S aureus.7 As early as the 1800s, this microorganism was implicated in infectious processes. The wide use of penicillin to treat common infections in the 1940s quickly produced penicillin resistance. In the 1950s, hospital prevalence rates of penicillin-resistant S aureus were approximately 40%, but rose to 80% by the 1960s.8 To counter this resistance, methicillin, a semisynthetic penicillinase-resistant penicillin, was introduced in 1960, but methicillin-resistant S aureus strains were already emerging within 1 year.9

MRSA is defined as an isolate of S aureus that demonstrates resistance to any semisynthetic penicillin.2 Methicillin resistance in S aureus is brought about by the methicillin-resistant gene (mecA), which encodes for the production of penicillin-binding protein not present in methicillin-susceptible strains of S aureus. Once S aureus is detected, testing via polymerase chain reaction is used to detect the presence of the mecA gene.10 MRSA can be further divided into two subtypes, healthcare-associated MRSA (HA-MRSA) and CA-MRSA. As their names suggest, MRSA is differentiated by the method of acquisition of infection and the population it infects (Table 1).

Table 1. Comparison of HA-MRSA and CA-MRSA Infection Risk Factors
HA-MRSA InfectionsCA-MRSA Infections
Elderly/resident long-term care facilityYoung children/daycare attendees
Prolonged hospitalizationCertain ethnic groups: African-American, Native Americans
Hospitalization within past yearAthletes
Intensive care unit admissionMen who have sex with men
SurgeryIncarcerated individuals
Presence of invasive medical devicesMilitary members
Broad spectrum antibiotic useIntravenous drug users
Immunocompromised statusFrequent antibiotic users
Recent MRSA exposureObesity
Poor hygiene

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Healthcare-Associated MRSA 

Although the focus of this article is CA-MRSA, the differences between HA-MRSA and CA-MRSA are important to understand and recognize. HA-MRSA is typically seen in patients who have recently been hospitalized (in either an acute care or long-term facility), and risk factors include being elderly, intensive care unit admission, surgery, dialysis, presence of invasive medical devices, history of broad-spectrum antibiotic use, and being in an immunocompromised state.2, 11, 12 Researchers have linked patient diagnosis of HA-MRSA to longer lengths of stay, increased costs, and a 5-fold increase in the risk of in-hospital death.13

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Community-Associated MRSA 

CA-MRSA is defined as MRSA infections in individuals who lack established risk factors14, and the profile of individuals who are at risk for CA-MRSA differs significantly from those who are at risk for HA-MRSA (Table 1). CA-MRSA is often seen in otherwise healthy individuals, especially those who have not been hospitalized within the past year. It has also been identified in specific subgroups such as daycare center attendees, members of sports teams, prison inmates, and military personnel.15, 16 Other groups with which CA-MRSA infections have been associated are Pacific Islanders, Alaskan Natives, Native Americans, men who have sex with men, intravenous drug users, and frequent users of antibiotics.17, 18, 19 Conditions that have been identified as contributing to the transmission of CA-MRSA include poor personal hygiene, sharing of personal items, overcrowded living conditions, and a lack of healthcare access.20, 21 Although seen in a relatively healthy patient population, CA-MRSA has been associated with significant skin and soft tissue infections and severe and invasive staphylococcal and musculoskeletal infections.18

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Clinical Presentation of CA-MRSA 

Infection with CA-MRSA does not have a clearly defined and specific clinical presentation with an etiology that may be immediately recognizable. Skin and soft tissue infections with associated boils, furuncles, carbuncles, abscesses, and localized cellulitis are often present but may be mistaken for other skin disorders, especially when cultures are not obtained. Outpatient infections resulting from CA-MRSA may be mild and self-limiting, with only slight redness and tenderness reported by patients. Patients may also present with reports of a “spider bite” that resembles a raised, red lesion or vague complaints of small bumps.18 In more severe cases, deep abscesses may be present that require hospitalization, intravenous antibiotics, and surgical debridement.22

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MRSA and Women's Health 

As a population, adolescents and young women have been overlooked as both potential recipients and carriers of CA-MRSA. This may be due to a variety of factors among providers including a lack of knowledge about susceptible patients, failure to identify risk factors, and confusion of presenting symptoms with other infections or injuries.

Obstetrics 

CA-MRSA within the obstetric population has been well documented. Researchers have demonstrated that MRSA colonization is a frequent finding with pregnant women and is responsible for a variety of puerperal infectious complications, including infections of caesarean and episiotomy incisions.4, 23 Maternal CA-MRSA infection has been identified as a causative agent in post partum mastitis, and MRSA-related mastitis infections have increased significantly in the past decade.13, 24, 25

Additionally, neonatal colonization and infection with CA-MRSA is becoming a more common finding in hospital newborn nurseries.26, 27 Because MRSA is able to survive for months on hospital fomites28, determining the source of nursery infections and eliminating transmission are difficult. Transmission among post partum patients has also been implicated in nursery and maternity unit outbreaks.27 Other factors that may predispose newborn nurseries to CA-MRSA infections include inadequate hand washing and staff members not observing universal precautions, neonatal circumcision, and lack of infants rooming with mothers after delivery.29

Gynecology 

As removal of pubic hair becomes a normative trend30, the vulva and pubic region is increasingly susceptible to infection by CA-MRSA. Mechanical techniques to groom or remove pubic hair such as shaving and waxing create microabrasions that serve as portals for infection and contribute to the spread of not only MRSA but also other infectious pathogens, including Molluscum contagiosum, human papillomavirus (HPV), and herpes simplex virus (HSV).30, 31, 32 In fact, Thurman et al.34 conducted a study to assess the incidence of MRSA among women with vulvar abscesses. These researchers conducted a retrospective chart analysis of 133 patients who presented for evaluation of vulvar abscesses at a large county hospital in Texas between October 2006 and March 2008. None of the patients had been hospitalized within 30 days of their visit. MRSA was isolated from the vulvar cultures in 85 of the 133 cases (64%).33 This report's findings are consistent with those of previous studies of the prevalence of MRSA in skin and soft tissue infections.3, 34

MRSA colonization and sexual transmission have been reported among men who have sex with men.35 Additionally, clinicians have documented the fact that colonization of the genital area with CA-MRSA among heterosexual partners can result in the spread of the pathogen through sexual activity and contribute to recurrent genital infection among otherwise healthy individuals.20 According to those authors, the intimate contact of sexual activity coupled with the presence of skin breakdown (shaving/waxing injuries) or HSV lesions can result in dissemination of CA-MRSA among sexual partners and increased spread of the disease within a community.20

The following case study provides an example of outpatient presentation of CA-MRSA, differential diagnoses, and treatment.

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Case Study 

Emily is a 20-year-old female who presented to the primary care clinic with complaints of a “sore” in her pubic area. She reported being sexually active for the past 3 months and stated that her current boyfriend has been her only sexual partner. She was teary and concerned that she had herpes, after looking up her symptoms on the Internet. Emily reported that her mother was unaware that she is sexually active and requested confidential care.

Her last menstrual period had been 3 weeks previously, and she denied any significant medical or surgical history. She reported no known drug allergies, and her social history was negative for alcohol, tobacco, and recreational drug use.

Upon questioning, Emily stated that the sore was red and very painful to the touch, and even clothing rubbing against the area was uncomfortable. She reported that she first noticed some small red bumps 4 days previously but thought it might be irritation from shaving. On the morning of her visit, the area “looked like a hole” and had some “yellow stuff” around the edges. She denied fever or chills, could not identify any other precipitating symptoms, and denied recently taking medications. She stated that she used condoms for birth control “all the time” and that her boyfriend, who was also 20 years old, denied having any previous sexual partners. He also denied having any pubic sores or lesions.

Emily's examination revealed a solitary 2-cm circular lesion on her lower mons pubis. Her pubic hair was absent secondary to shaving, and there was minor folliculitis present. The lesion was swollen, with beefy red edges, and had a moderate amount of yellow exudate draining from the center. It was very painful to light pressure, and palpable bilateral inguinal nodes were present.

Laboratory results revealed the following: the patient was negative for chlamydial and gonorrheal infections; nonreactive to Rapid HIV and rapid plasma reagin (RPR) tests; negative for HSV infection; and positive for MRSA infection by microbiology culture.

Emily was informed that her laboratory results were negative for sexually transmitted infections but revealed a MRSA skin infection. Oral antibiotics were initiated with double-strength sulfamethoxazole-trimethoprim twice a day for 7 days. At follow-up 1 week later, Emily reported finishing the antibiotics and significant healing had occurred.

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Treatment Options 

In conjunction with expert opinion, the Centers for Disease Control and Prevention has published guidelines for the treatment of CA-MRSA.18 Current recommendations include incision and drainage (I&D) as the initial treatment for skin lesions such as boils, abscesses, and furuncles. In uncomplicated infections, this may be the only treatment that is necessary. In otherwise healthy, immunocompetent adults, antibiotics should be considered in the presence of fever, systemic dissemination of disease, rapid progression of local infection or cellulitis, or failure to respond to I&D.18 Even without strong evidence for the use of antibiotics, researchers have shown that most providers will initiate antibiotic therapy when CA-MRSA is suspected or diagnosed.36 The choice of antimicrobial therapy is complicated by antibiotic resistance to CA-MRSA. Antibiotics commonly used for skin and soft tissue infections such as β-lactam antibiotics (penicillin and cephalosporins) and macrolides/azalides (erythromycin, clarithromycin, and azithromycin) are often resistant to many strains of CA-MRSA.22 The most commonly used oral antibiotics for the treatment of outpatient CA-MRSA are detailed in Table 2.

Table 2. Common Oral Antibiotics for CA-MRSA Infection
AgentUsual DoseConsiderations
Clindamycin300-450 mg three times per dayCan be costly; can result in Clostridium difficile infection
Doxycycline100 mg twice dailySide effects include nausea and vomiting, photosensitivity; contraindicated in pregnancy: category D*
Minocycline100 mg twice dailySide effects include nausea and vomiting, photosensitivity; contraindicated in pregnancy: category D*
SMZ-TMP DS†1-2 tablets twice dailySulfa allergy may cause rash and hives; nausea and vomiting, photosensitivity
Rifampicin600 mg four times per dayCannot be used a single agent; often combined with SMZ-TMP

* Category D indicates use in pregnancy has demonstrated a risk to the fetus.

† Double-strength sulfamethoxazole-trimethoprim (800 mg to 160 mg)

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Carrier Status 

Researchers have documented the fact that colonization with S aureus typically precedes MRSA infection and that the most common site for colonization is the anterior nares.37 Colonization of multiple body sites such as the groin or urine or wounds has been associated with a more persistent carrier state and increased transmission.38, 39 Risk factors for CA-MRSA colonization are similar to risk factors for infection and include prior MRSA infection, previous antibiotic use, overcrowding, close personal contact with an individual with CA-MRSA infection (including sexual contact), participation in contact sports, sharing personal items such as razors or towels, obesity, poor hygiene, and any form of skin breakdown that may serve as an entrance point for S aureus.20, 21

Once carrier status has been identified, there is no set recommendation for treatment of asymptomatic carriers within the outpatient population. Decolonization attempts with patients in hospital settings have been successful in temporarily eliminating CA-MRSA, but recolonization is often reported, and standardized decolonization therapy for individuals in the community has not been established.40 Previously used therapies include topically applied nasal mupirocin and antiseptic skin washes with agents such as chlorhexidine. These may be initiated with or without systemic antibiotic treatment, but success rates have varied greatly, and many patients are recolonized within 3 to 6 months of treatment.41, 42, 43 Even so, it may be prudent to attempt decolonization with targeted individuals, especially those with multiple episodes of CA-MRSA skin infections or documented transmission between close personal contacts.18

In the women's health population, it is now recognized that in addition to the nares, the vagina is a possible reservoir for CA-MRSA and should be considered when women (and potentially their sex partners) present with recurrent genital lesions.4, 20 Although vaginal cultures can confirm carrier status, there are no current recommendations for vaginal decolonization. Simor et al.44 suggest that combined therapy with oral and topical antibiotics might reduce transmission and eliminate colonization. Reichman and Sobel23 posit that 2% clindamycin vaginal gel may hold promise for eliminating vaginal colonization, but there is no established regimen, and further work is needed.

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Clinical Implications 

Patient education is at the cornerstone of CA-MRSA reduction and management, and nurse practitioners are often central to the delivery of patient information. For patients with an active CA-MRSA infection, education is focused upon eliminating the infection, decreasing transmission, and preventing reinfection. Frequent and careful hand washing can prevent the spread of infection, especially with household contacts. For the women's health population, this must also include sexual contacts if the patient is sexually active. Depending on the location, draining sores or lesions should be covered with clean, dry bandages, and care should be taken to avoid contact with drainage or soiled bandages and clothing. Furthermore, patients with genital lesions need to be instructed to abstain from sexual activity to avoid transmission to partners. Personal items such as razors, towels, clothing, and soap should not be shared, and meticulous hand washing and regular bathing should be encouraged.20, 18 After initiation of treatment, improvement should be seen within 48 hours. Patients need to be provided with specific information that details warning signs of systemic infection and the need for more aggressive treatment.

Shaving and/or waxing pubic hair is a common grooming practice, and patients with genital CA-MRSA who also remove their pubic hair require education about how this activity may contribute to infection and ways to reduce the chance of reoccurrence. While stopping pubic hair removal will decrease the chance of skin damage due to mechanical trauma, many patients are reluctant to forego this type of grooming.30 Therefore, healthcare providers need to inquire about hair removal techniques, including razor type (blade or electric), wet or dry shaving, frequency of blade replacement, and the use of any shaving lotions or depilatories. For patients who have their pubic hair removed by waxing or laser techniques, providers need to stress the importance of using reputable or licensed facilities.30 A candid discussion about the frequency of hair removal, techniques used, and potential side effects will allow for improved assessment of risk factors and enhanced educational opportunities for patients.

Although CA-MRSA infection is not considered a sexually transmitted infection, genital transmission among sexual partners is possible20 and represents another area for patient education. Patients with a diagnosis of genital CA-MRSA infection need to be queried about their sexual contacts and whether they have noticed any bumps or small pustules in the groin area of their partners. To eliminate the chance of reinfection, examination of sexual partners may be advisable. If evidence of CA-MRSA carriage exists, implementing a treatment plan aimed at decolonization of both parties can be considered. Additionally, patients may be unaware of the potential for sexual transmission or believe that condoms will protect against all infections, including that by CA-MRSA. A discussion of sexual practices, including number of current sexual partners and screening for sexually transmitted infections is necessary in order to provide comprehensive care to patients with a diagnosis of genital CA-MRSA infection.

Prevention of CA-MRSA is ideal but can be difficult, given the prevalence rates and numerous contributing risk factors.3, 20, 21 Nurse practitioners who care for women need to provide their female patients with basic information about CA-MRSA infection as part of overall health education that stresses disease reduction and promotion of a healthy lifestyle. This may include basic information for hygiene, hand washing, personal care items, and sexual health. For those patients who live in crowded conditions, encouraging the disinfection of common surfaces and regular laundering of clothing and bedding may be help prevent infection.18

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Conclusion 

CA-MRSA infection within the women's health population is occurring more frequently and is most likely spread by a combination of vaginal colonization, intimate contact between sexual partners, and microabrasions to the genital skin. Clinical presentation is variable and may be confused with other diseases by both patients and providers. Nurse practitioners who provide women's healthcare must be aware of CA-MRSA infection risk factors and symptoms and should consider infection by CA-MRSA as a differential diagnosis when patients present with genital rashes, bumps, lesions, or sores. Increased awareness among providers, reduction of risk factors, and patient education are currently the best strategies in the overall control of CA-MRSA within the community.

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References 

  1. Fridkin S , Hageman J , Morrison M , Thomson Sanza L , Como-Sabetti K , Jernigan J , et al.   Methicillin-resistant Staphylococcus aureus disease in three communities . N Engl J Med . 2005;352:1436–1444
  2. Kurkowski C . CA-MRSA, the new sports pathogen . Orthop Nurs . 2007;26(5):310–314
  3. Moran G , Krishnadasan A , Gorwitz R , Fosheim G , McDougal L , Carey R , et al.   Methicillin-resistant Staphylococcus aureus among patients in the emergency department . N Engl J Med . 2006;355:666–674
  4. Chen KT , Huard RC , Della-Latta P , Saiman L . Prevalence of methicillin-sensitive and methicillin-resistant Staphylococcus aureus in pregnant women . Obstet Gynecol . 2006;108(3):482–487
  5. Kreibs JM . Methicillin-resistant Staphylococcus aureus infection in the obstetric setting . J Midwifery Womens Health . 2008;53(3):247–250
  6. Diekema DJ , Pfaller MA , Schmitz FJ , et al.   Survey of infections due to Staphylococcus species: frequency of occurrence and antimicrobial susceptibility of isolates collected in the United States, Canada, Latin America, Europe, and the Western Pacific region for the SENTRY Antimicrobial Surveillance Program, 1997–1999 . Clin Infect Dis . 2001;32(Suppl 2):S114–S132
  7. Centers for Disease Control and Prevention  . Community-associated MRSA information for clinicians . Available at: http://www.cdc.gov/ncidod/dhqp/ar[lowem]mrsa[lowem]ca_clinicians.html 2005; Accessed January 21, 2010
  8. Chambers HF . The changing epidemiology of Staphylococcus aureus . Emerg Infect Dis . 2001;7:178–182
  9. Corriere MD , Decker CF . MRSA: an evolving pathogen . Dis Mon . 2008;54(12):751–755
  10. Enright M , Robinson DA , Randle G , Feil E , Grundmann H , Spratt B . The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA) . Proc Natl Acad Sci U S A . 2002;99(11):7687–7692
  11. Andrews W , Schelonka R , Waites K , Stamm A , Cliver S , Moser S . Genital tract methicillin-resistant Staphylococcus aureus: Risk of vertical transmission in pregnant women . Obstet Gynecol . 2008;111:113–118
  12. Dunlap J . Methicillin-resistant Staphylococcus aureus in critical care areas . Crit Care Nurs Clin North Am . 2007;19:61–68
  13. Jarvis W , Schlosser J , Chinn R , Tweeten S , Jackson M . National prevalence of methicillin-resistant Staphylococcus aureus in inpatients at U.S. health care facilities, 2006 . Am J Infect Control . 2007;35(19):631–637
  14. Noskin G , Rubin R , Schentag J , Kluytmans J , Hedblom E , Smulders M , et al.   The burden of Staphylococcus aureus infections on hospitals in the United States . Arch Intern Med . 2005;165:1756–1761
  15. Jernigan J , Arnold K , Heilpern K , Kainer M , Woods C , Hughes J . Methicillin-resistant Staphylococcus aureus as community pathogen. Emerg Infect Dis . Available at: http://www.cdc.gov/ncidod/EID/vol12no11/06-0911 Accessed January 6, 2010
  16. Daum R . Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus . N Engl J Med . 2007;357:380–390
  17. McCartney P . Methicillin-resistant Staphylococcus aureus in maternal child nursing . Mat Child Nurs . 2007;32:193
  18. Borlaug G , Davis JP , Fox BC . Community associated methicillin-resistant Staphylococcus aureus: guidelines for clinical management and control of transmission . Available at: http://dhfs.wisconsin.gov/communicable/pdf_files/CAMRSAGuide_1105.pdf 2005; Accessed December 27, 2009
  19. Gorwitz RJ , Jernigan DB , Powers JH , Jernigan JA , Participants in the CDC-Convened Experts' Meeting on Management of MRSA in the Community  . Strategies for clinical management of MRSA in the community: Summary of an experts' meeting convened by the Centers for Disease Control and Prevention . Available at: http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html 2006; Accessed December 27, 2009
  20. Graffunder E , Venezia R . Risk factors associated with nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection including previous use of antimicrobials . J Antimicrob Chemother . 2002;49:999–1005
  21. Cook HA , Furuya EY , Larson E , Vasquez G , Lowy FD . Heterosexual transmission of community-associated Methicillin-resistant Staphylococcus aureus . Clin Infect Diss . 2007;44:410–413
  22. Turabelidze G , Lin M , Wolkoff B , Dodson D , Gladbach S , Zhu B . Personal hygiene and methicillin-resistant Staphylococcus aureus infection . Emerg Infect Dis . 2006;12:422–427
  23. Reichman O , Sobel JD . MRSA infection of the buttocks, vulva, and genital tract in women . Curr Infect Dis Rep . 2009;11:465–470
  24. Laibl VR , Sheffield JS , Roberts S , McIntire DD , Trevino S , Wendel GD . Clinical presentation of community-acquired methicillin-resistant Staphylococcus aureus in pregnancy . Obstet Gynecol . 2005;106:461–465
  25. Reddy P , Qi C , Zembower T , Noskin GA , Bolon M . Postpartum mastitis and community-acquired methicillin-resistant Staphylococcus aureus . Emerg Infect Dis . 2007;13:298–301
  26. Stafford I , Hernandez J , Laibl V , Sheffield J , Roberts S , Wendel G . Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization . Obstet Gynecol . 2008;112:533–537
  27. Bratu S , Eramo A , Kopec R , et al.   Community-associated methicillin-resistant Staphylococcus aureus in hospital nursery and maternity units . Emerg Infect Dis . 2005;11:808–813
  28. Nguyen DM , Bancroft E , Mascola L , Guevara R , Yasuda L . Risk factors for neonatal Methicillin-resistant Staphylococcus aureus infection in a well-infant nursery . Infect Control Hosp Epidemiol . 2007;28:406–411
  29. Hota B . Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infections? . Clin Infect Dis . 2004;39:1182–1189
  30. Kitajima H . Prevention of methicillin-resistant Staphylococcus aureus infections in neonates . Pediatr Int . 2003;45:238–245
  31. Trager JDK . Pubic hair removal:-pearls and pitfalls . J Pediatr Adolesc Gynecol . 2006;19:117–123
  32. Braue A , Ross G , Varigos G , Kelly H . Epidemiology and impact of childhood molluscum contagiosum: a case series and critical review of the literature . Pediatr Dermatol . 2005;22:287–294
  33. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3
  34. Thurman AR , Satterfield T , Soper D . Methicillin-resistant Staphylococcus aureus as a common cause of vulvar abscesses . Obstet Gynecol . 2008;112:538–544
  35. Klevens M , Morrison M , Nadle J , Petit S , Gershman K , Ray S , et al.   Invasive methicillin-resistant Staphylococcus aureus infections in the United States . JAMA . 2007;298(15):1763–1771
  36. Shastry L , Rahimian J , Lascher S . Community-associated Methicillin-resistant Staphylococcus aureus skin and soft tissue infections in men who have sex with men in New York City . Arch Intern Med . 2007;167:854–857
  37. Gorwitz RJ . The role on ancillary antimicrobial therapy for treatment of uncomplicated skin infections in the era of community-associated methicillin-resistant Staphylococcus aureus . Clin Infect Dis . 2007;44:785–787
  38. Kluytmans J , van Belkum A , Verbrugh H . Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks . Clin Microb Rev . 1997;10:505–520
  39. Eveillard M , de Lassence A , Lancien E , Barnaud G , Ricard JD , Joly-Guillou ML . Evaluation of a strategy of screening multiple anatomical sites for methicillin-resistant Staphylococcus aureus at admission to a teaching hospital . Infect Control Hosp Epidemiol . 2006;27(2):181–184
  40. Harbarth S , Liassine N , Dharan S , et al.   Risk factors for persistent carriage of methicillin-resistant Staphylococcus aureus . Clin Infect Dis . 2000;31:1380–1385
  41. Laupland KB , Conly JM . Treatment of Staphylococcus aureus colonization and prophylaxis for infection with topical intranasal mupirocan evidence-based review . Clin Infect Dis . 2003;37:933–938
  42. Coia JE , Duckworth GJ , Edwards DI , et al.   Guidelines for the control and prevention of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities . J Hosp Infect . 2006;63(Suppl. 1):S1–44
  43. Perl TM , Cullen JJ , Wenzel RP , et al.   Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections . N Engl J Med . 2002;346:1871–1877
  44. Simor AE , Phillips E , McGeer A , et al.   Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization . Clin Infect Dis . 2007;44:178–185

 In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.

PII: S1555-4155(10)00119-4

doi:10.1016/j.nurpra.2010.02.023

The Journal for Nurse Practitioners
Volume 6, Issue 6 , Pages 435-441, June 2010

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