CorrectCare

LA Confidential
County Jail Solves MRSA Mystery

By John H. Clark, MD, CCHP-A

If your jail or prison has had no cases of methicillin-resistant Staphylococcus aureus infection recently, watch out: MRSA is on its way to your facility. Sometimes defined as multidrug-resistant Staph aureus, MRSA is on the rise nationwide and is especially prevalent in the public health laboratories that are our nation’s prisons and jails.

The Los Angeles County jail system became well-acquainted with MRSA over the past two years, and in response has implemented a rigorous set of protocols for diagnosing, treating and, perhaps most importantly, preventing MRSA among our inmate population.

First, let’s look at the chronology of events. In September 2001, we began to receive occasional complaints by inmates of spider bites at several of our facilities. Spider bites can be nasty, and while we did not see any severe infections during this episode, there were enough reports to cause some concern.

In response, we developed a physician protocol that involved culturing, starting patients on antibiotics and doing incision and drainage when appropriate and feasible. We also developed briefing notes for the physician staff to facilitate treatment of these patients.

Detective Work
By December insect bite reports were increasing steadily, so we determined to discover what was happening. The sheriff’s department medical staff worked closely with custody staff, as well as the county public health department, to inspect each housing area. We found no nests or other evidence that any insects were reproducing or thriving. Still, just in case we were missing them, we confirmed that the contractor who handled our pest control program was using pesticides effective against insects and spiders, and we fumigated the sites.

Within a month or two, we began to receive reports of insect bites at additional jail facilities. We noticed that most of the reported bites occurred below the waist, so we took a close look at our laundry facility, a big operation that serves all of the L.A. County jails. Again, we did a complete inspection and made sure that procedures were being followed, but no insects or incriminating evidence was found. Again, we fumigated the site.

In April 2002, the focus of the reported bites shifted to yet another jail. We went through the same drill, but this time we captured five spiders. An entomologist, however, determined that they were harmless, nonbiting varieties.

Fingering the Culprit
The real breakthrough came right around the same time. In-depth epidemiological interviews with inmates revealed some behaviors of which we had not been aware. For example, inmates were sharing razors and other instruments, and were doing minor procedures such as popping boils. Not to point fingers, but we also learned of instances where inmates did not have adequate access to showers or personal hygiene items such as effective soap or toilet paper. These insights were like a lightbulb turning on because we knew that poor hygiene is an important factor in the spread of staph infections.

In May and June we took a hard look at the results of cultures we had taken and found an alarming number of MRSA infections. These weren’t apparent earlier because of the way our jail system handles lab results. The results are entered into the electronic medical record and, due to the frequent movement of inmates between facilities, may not be seen by the physician who ordered the test. To remedy this, all culture results are now reviewed by the medical services communicable disease unit.

At this point, we notified all custody staff that we had identified MRSA as the source of the skin lesions and explained how it was being spread. We also requested assistance from the Los Angeles County Department of Health Services.

Besides cultures, we also reviewed all hospitalizations related to MRSA, and all inmate deaths in 2001 that were coded as related to sepsis.

New Protocols
Working with the health department, we immediately developed a joint task force to more thoroughly examine all culture results, analyzing them by facility and other characteristics. This revealed that for 75% of the people cultured, results were positive for MRSA. Given that MRSA incubation periods are between 1 and 10 days, analysis also showed that about 10% of new admissions were infected when they arrived.

Molecular fingerprinting of the bacteria revealed that the outbreaks throughout the jail were of a single clone, which also is consistent with the type of MRSA seen in recent outbreaks of skin infections in Los Angeles County and nationwide.

At this point, in October 2002, we made a clinical decision that, in addition to seeing the patient, doing the I&D and culture, and waiting for the results, we would automatically implemented the revised treatment protocol. This involves an antibiotic regimen using the following drugs:
· Bactrium DS (1 tab PO BID x 7 days) or Clindamycin (300 mg PO QID x 7 days)
   if patient is allergic to Bactrium or other sulfur drugs
· Rifampin (300 mg PO BID x 7 days)

By the end of 2002, still working with the health department we conducted another briefing for all medical staff, we briefed all custody staff on all shifts at all facilities, and we produced an educational video for custody staff and inmates.

This experience also led to the formation of a permanent MRSA task force that meets monthly to review the progress we have made in carrying out its recommendations (see box above) and reducing infections. The task force comprises representatives from the sheriff’s department, both medical and custody staff, the county health department and its acute communicable disease unit, and the Centers for Disease Control.

While the percentage of MRSA-positive cultures has dropped from the 75% we experienced before we revised the treatment protocol, we seem to have plateaued at somewhat more than 50%, or about 110 positive culture per month. This may be attributable to the fact that we are doing very aggressive culturing. However, until this figure drop below 50% we will continue to follow the current protocol, and it’s likely to be quite awhile before the incidence of MRSA declines significantly.

While our close collaboration with the county health department was critical in combating this outbreak, the experience suggests that it would have been helpful if our communicable disease management program had already had a section addressing unusual outbreaks such as MRSA.

Finally, while it remains unclear exactly what works best in such situations, without question a multifaceted approach can be very effective.

— About the author:  John H. Clark, MD, CCHP-A, is chief medical officer for the County of Los Angeles Sheriff’s Department. This article is based on his presentation at the Clinical Updates in Correctional Health Care conference in Anaheim, CA, in April. Clark wishes to thank two colleagues whose efforts were invaluable in identifying this outbreak: Martha Tadesse, public health nurse in the communicable disease unit of the Medical Services Bureau, and Elizabeth Bancroft, MD, epidemiologist for the Los Angeles County Department of Health Services.

[This article first appeared in the Summer 2003 issue of CorrectCare.]