In this July/August issue dedicated to the tangible and intangible aspects of massage and bodywork, Pathology Perspectives will focus on an extremely tangible part of the life of any healthcare provider who comes in close contact with other people: skin infections. Specifically, this article addresses a pathogen called methicillin-resistant Staphylococcus aureus, or MRSA.
MRSA has become a hot health topic, partly because statistics recently compiled by the Journal of the American Medical Association (JAMA) indicate that both the incidence and the mortality associated with this pathogen are higher than previously thought.1 Because MRSA can be spread through skin-to-skin contact, it is important for massage therapists to be well-informed about public health issues like this that put us and our clients at risk for a potentially life-threatening infection.
What is MRSA?
MRSA is a type of staph bacteria that colonize human skin and sinus passages. They are resistant to a group of antibiotics called beta-lactams, which includes amoxicillin, methicillin, oxacillin, and penicillin.
Widespread testing indicates that up to 30 percent of the U.S. population is colonized with some kind of staph. But only about 1 percent of us carry the MRSA types of bacteria.2 It is important to point out that colonization is not the same as active infection, although a person who carries MRSA can spread it to other people who may be vulnerable if good hygienic practices aren’t followed.
HA-MRSA Versus CA-MRSA
Staphylococcus bacteria have probably been around longer than humans. These bacteria can infect nearly every body system, invading healthy cells and producing corrosive toxins. Drug-resistant forms of staph were noted in the 1950s and 1960s, just a few years after the introduction of antibiotics, which shows how efficiently bacteria mutate to adjust to their environmental challenges. The first strains of drug resistant staph were confined to hospital settings and thus called nosocomial, or hospital-acquired methicillin resistant Staphylococcus aureus (HA-MRSA). These infections were usually related to contaminated devices like catheters, dialysis equipment, or ports; pneumonia; surgical wounds; and urinary tract infections. HA-MRSA is still prevalent, and is considered a leading cause of hospital acquired infections (especially pneumonia), resulting in nearly 90,000 deaths each year.3
Since the development of the first MRSA bacteria, however, it has evolved into at least three distinct strains, each with unique strengths and weaknesses—and not all of them are hospital-based pathogens anymore. As far back as the 1980s, there have been reports of drug-resistant staph infections in people who had not recently been in a hospital or other healthcare setting. It wasn’t until the current decade, however, that the incidence of these community-acquired infections got a lot of attention. These bacteria are referred to as CA-MRSA.
CA-MRSA has some distinct differences from HA-MRSA, and because massage therapists are particularly vulnerable to the community-acquired form, it is important to make note of them (See chart to the right).
What Does a CA-MRSA Infection Look Like?
Most community-acquired MRSA infections look like a large pimple or boil: a large red pustule develops in the skin, often where an open sore or lesion provided a portal of entry. It is hot and painful and may drain some fluid. Many people assume that the lesion is a spider bite. Left untreated, the bacteria may invade into deeper tissues and even set up infections in the lungs (causing an extremely aggressive form of pneumonia) or the bloodstream (causing life-threatening sepsis).
In rare situations, MRSA skin infections can be atypical; they may look like flattened ulcers or folliculitis. The only way to be sure what type of infection is present is to culture it (take a sample and grow it in a lab), which can take 48 hours or more. Unfortunately, this is becoming an increasingly important step in order to take the right drug for the right bug—using the wrong antibiotics only contributes to the risk of developing more resistant strains. This is why many emergency room doctors now recommend draining of the lesion thoroughly instead of depending on antibiotics to clear the infection.
How Can CA-MRSA be Prevented?
The Centers for Disease Control promote Five Cs for CA-MRSA control:4
Clean, clean, clean. Keep yourself and the things you touch clean.
Contact. MRSA can be spread through direct skin-to-skin contact, so avoid this if any infection is suspected.
Contaminated items and surfaces. Avoid them.
Crowding. Be especially careful in crowded living circumstances.
Cuts and sores. These are portals of entry for pathogens. Keep them covered.
What About Massage and MRSA?
MRSA, whether it is community or hospital acquired, needs to figure into the hygiene planning for every massage therapist. When we take universal precautions, we operate under the supposition that all of our clients might be carrying a communicable disease.
Guidelines for healthcare workers make the following suggestions to help control the spread of MRSA and other potentially infectious agents. They have been extended below to apply to massage therapy settings as well:5
Use a 10 percent bleach solution to clean surfaces. This can include door knobs, massage tables and face cradles, switch plates, and anything else that a client might touch. Bleach solutions lose their potency quickly, so these need to be remixed weekly at least.
Wash hands in running warm (not hot) water with plain (not antimicrobial) soap. Hot water and antimicrobial soap are more likely to cause skin irritations that actually increase, rather than decrease, the risk of picking up an infection.
When warm running water and plain soap are not available, use an alcohol-based cleansing gel. Use the amount recommended, and rub hands until it has all been absorbed or evaporated. This is a poor second to standard hand washing, but it is sufficient as a short-term solution.
Wash linens (also bolster covers, heating pad covers, pillow cases, or any other fabrics that clients encounter) in hot water, and dry them on high heat. Bleach can damage fabrics, and it can cause reactions in users if it isn’t all rinsed out, so it is not always practical.
Sanitize any other equipment that clients touch, including hot and cold stones, hot or cold packs, and massage tools.
In my role as a go-to person for questions about massage and pathology, I get letters fairly frequently from massage therapists who are legitimately concerned about community-acquired MRSA. The good news is that most of these questions have relatively simple answers:
What if my client is a MRSA carrier? Remember that to be colonized by staph does not mean that an infection is current or threatening. About a third of us are carriers of some kind of staph; MRSA carriers just have a tougher variety.
What if I am a MRSA carrier? As long as you follow basic hygiene rules you will not share your staph with others. Be especially careful about touching your face or wiping your nose, as these bacteria can congregate in the sinuses.
How long is a person contagious after an infection? Skin infections with MRSA usually have a good prognosis if they are treated correctly (this means with incision and draining, and/or the correct antibiotics). The best person to consult on this question is the treating doctor, because the answer may be different with a person’s immune system activity, age, the size and location of the lesion, and other variables.
What if I am exposed and I don’t know? If your client has an active MRSA infection on the surface of his or her skin and you pick up some passengers, you may never know, and you may never be in any danger. Assuming you have covered any open lesions, the bacteria will be sloughed off the next time you wash your hands. But this is yet another good reason to take excellent care of your hands, from trimming fingernails and cuticles, to covering the scrape where your knuckle got too close to the cheese grater last night.
What if I think of another question later? Go to your phone book. Call the main number of your nearest hospital, and ask to be connected to the infection control department. You’ll probably get a machine, but every time I have used this very valuable resource I have received a return call from a helpful, knowledgeable infection control specialist within a couple of days.
Don’t Panic!
We are bombarded by pathogens on a daily basis, and we hardly ever get sick. This is because our nonspecific and specific immune defenses usually do a truly remarkable job of protecting us from the threat of invasion. Our best defense is knowledge, and now you know even more reasons to take excellent care of your own health and the hygiene of the space where you work.
Ruth Werner is a writer and educator who teaches several courses at the Myotherapy College of Utah and is approved by the NCTMB as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.
Notes
1. Thomas Ward, “Spread of MRSA: Past Time for Action,” Medscape Journal of Medicine 10, no. 2 (2008): 32.
2. Community-Associated MRSA Information for Clinicians. Centers for Disease Control and Prevention. www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_clinicians.html (accessed March 2008).
3. Andrew Shorr, “MRSA—A Clinical Perspective: An Expert Interview With Andrew F. Shorr, MD, MPH, FCCP,” Medscape Pulmonary Medicine. www.medscape.com/viewarticle/567251 (accessed March 2008).
4. Community-Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA). 2007 American Academy of Dermatology. www.aad.org/pm/temp/mrsa/qa.html (accessed March 2008).
5. Ruth Werner, A Massage Therapist’s Guide to Pathology, 4th ed. (Baltimore: Lippincott, Williams & Wilkins, 2009), 10–13.