MRSA

An Analysis of MRSA in the Ecological/Evolutionary and Sociopolitical/Economic

Anthropological Perspectives

By Liz Rolf

Anthropology 3212

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All conscious inpatients at Barnes-Jewish Hospital in St. Louis, Missouri, become

familiar with methicillin-resistant staphylococcus aureus (MRSA) within 24 hours of their

admission. MRSA is so feared by the medical community that standard infection protocol at

Barnes-Jewish Hospital requires all inpatients to be screened for MRSA colonization every 24

hours for the duration of their stay. Screening is conducted by swabbing the patient’s nasal

cavities and then submitting the swab to the hospital’s diagnostic microbiology lab to be

cultured. Failing to perform this test on schedule can be grounds for termination of the nurse

whose duty it was to obtain the test specimen. The reason for this screening is twofold: if a

person has MRSA bacteria present, it could infect the patient, or it could infect other, potentially

more vulnerable, patients. This is just one example of the actions the medical community takes

to attempt to reduce the impact of an infection that modern medicine created. There are many

other actions and options taken by both the medical community and the general public. Such

actions can be based in the science of the infection, in the culture that created the menace, or in

the choices that each individual might make. All of the actions we might take to combat MRSA

can be (and likely have been) studied by anthropologists from many different perspectives.

In order to analyze the MRSA epidemic from various anthropological perspectives, a

brief overview of MRSA is necessary. What we call MRSA is in truth any strain of

staphylococcus aureus that has acquired or developed resistance to methicillin, a potent

antibiotic and descendant of penicillin. In practice though, the exact strain of staphylococcus

aureus matters very little; the only thing that really matters to physicians is the resistance or

susceptibility to various antibiotics. MRSA infections usually begin with the skin, causing the

development of small red pimple-like bumps, which can rapidly develop into deep abscesses

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(Mayo Clinic, 2012). If the infection is not caught quickly (approximately 24-72 hours after

appearance of bumps, but this can vary), the abscesses can burrow deep into the skin and the

infection can spread to the internal organs and the blood, causing sepsis (Mayo Clinic, 2012).

The rate of death from due to MRSA infection varies greatly depending upon the severity of the

infection at the time of diagnosis and upon the site of infection. Infection of the blood

(bacteremia) is usually considered to be the most serious presentation of MRSA (admittedly,

infection of the brain and spinal cord would likely be even worse, but it is far more difficult for

MRSA to get into the central nervous system than it is to get into the blood). MRSA bacteremia

is estimated to have a roughly 20% death rate (Pastagia et al., 2012). MRSA requires physical

contact to spread; it is not airborne (Mayo Clinic, 2012). This can happen through contact with

an infected wound or infected bodily fluids, or it can occur via contact with contaminated hands

or surfaces that have not been properly sterilized. Unfortunately, MRSA infections are not a rare

occurrence; approximately 80,461 invasive infections (infections that went beyond the outer

layers of the skin) occurred in the United States in 2011 (Dantes et al., 2013). Of those,

approximately 48,353 infections were hospital acquired; 14,156 were classified as hospital-onset

(likely acquired in outpatient healthcare settings); and 16,560 were community acquired (Dantes

et al., 2013).

The ecological/evolutionary perspective is the first perspective that should be used when

studying the MRSA epidemic, because it allows us to analyze the building blocks that laid the

foundation for MRSA’s explosion. In 1959, methicillin was licensed in England, and within one

year the first known methicillin-resistant staphylococcus aureus isolates were documented in a

British study (University of Chicago, 2010). The first hospital outbreaks occurred during the

early 1960s, and the first large-scale community outbreak occurred in intravenous drug users in

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Detroit in 1981 (University of Chicago, 2010). By 2008, healthcare-associated MRSA infection

rates had stabilized, but the rates of community-acquired infections continued to rise (University

of Chicago, 2010). While the only risk factor associated with healthcare-associated infections is

exposure to the healthcare system, risk factors for community-acquired infections are still being

discovered. To date, the populations at higher risk for community-acquired infections include:

athletes, individuals in jail or prison, members of the armed forces, HIV patients, sexually active

homosexual men, emergency room visitors, residents of urban areas, and indigenous populations

(University of Chicago, 2010). MRSA has become extremely prevalent for two main reasons: the

widespread use of potent antibiotics and the ability of S. aureus to colonize a person without

causing an active infection. Approximately 31.6% of the United States population is colonized

with S. aureus, and 0.84% of those carriers are colonized with MRSA (Graham et al., 2006).

Such colonies are usually located in the nasal passages. Those carriers are typically

asymptomatic until an opportunity presents itself for the infection to become active (such as

when the immune system weakens or when an open wound appears), but they are capable of

infecting others under the right circumstances. If nasal MRSA colonization is detected before it

becomes problematic, it can be treated with a seven day regimen of mupirocin (a topical

antibiotic). The ability of MRSA to colonize an individual without causing an active infection

makes it fairly easy to spread to other people. All a carrier has to do is wipe their nose and touch

a doorknob; anyone else can pick up the infection by touching that same doorknob and then

touching their skin. This is why hand washing is emphasized so frequently in healthcare settings:

assuming you don’t have any cuts or open wounds that touched an infected surface, you can just

wash off the bacteria before it can infect you.

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Antibiotic overuse is the single biggest factor influencing the spread of MRSA. The

development of methicillin resistance in S. aureus is a perfect fit for the ecological/evolutionary

perspective: we overused methicillin, which killed off the methicillin-susceptible S. aureus, and

which left the lucky few bacterial cells that possessed the methicillin-resistant trait alive and with

plenty of resources necessary to reproduce. In general infectious disease clinical practice,

antibiotics are given to up to 80% of patients, even though antibiotic use is only necessary 20%

of the time (Madigan et al., 2009). In up to 50% of those cases, inappropriate dosages or

treatment durations are given (Madigan et al., 2009). Patients who stop taking their antibiotics as

soon as they feel better, whether or not they actually finished the prescribed treatment regimen,

compound the problem. We also see dramatic overuse of antibiotics in livestock, where up to

50% of all antibiotics worldwide are given to farm animals (Madigan et al. 2009). That rate is up

to 80% in the United States (Madigan et al. 2009).

Why we overuse antibiotics is a complicated, multi-faceted issue that is best analyzed

through the sociopolitical/economic perspective. In farm animals, antibiotics are regularly used

in animal feed as a supplement, intended to promote growth and prevent infections, instead of

treating an infection when it arises. This is a common practice because it is easier and cheaper

than regularly examining livestock for signs of illness and infection. The FDA has repeatedly

attempted to change the regulations regarding antibiotic use in livestock, but their efforts have

always been blocked by republicans in the House and Senate, who cite the economic costs to

ranchers as the main reason for impeding regulation. The economic costs of drug-resistant

infections don’t seem to be of much concern to them, though.

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The American public plays many different roles in the spread of MRSA and other

antibiotic-resistant bacteria strains. Part of the blame lies in the misperception of antibiotics as a

cure-all for any infectious illness, and in the reluctance of doctors to deny their patients such a

request. Patients routinely request antibiotics for viral illnesses, and many doctors acquiesce.

There are two main reasons that cause patients to demand antibiotics, regardless of their need or

lack thereof. Some patients want antibiotics because they want a quick fix (or something that

they think is a quick fix, even when it isn’t). Many of these patients desire a quick fix because

their job doesn’t offer much (or any) paid sick leave, so these individuals are trying desperately

to minimize the amount of time they can’t work and thus lose money. There’s also the risk that,

in “at-will” employment states, that the individual could lose their job altogether. This factor that

contributes to the spread of antibiotic-resistant strains could be reduced by making paid sick

leave a required benefit provided by every employer for every job, thus giving patients time to

heal without the desperate worry of unemployment that drives them to seek inappropriate

medical care. The abysmal state of healthcare in the United States is another major contributing

issue. When individuals spend an absurd amount of money to see a doctor (with or without

insurance, the prices are still horrific), they often feel like they’ve been “cheated” if they leave the

office with nothing more than instructions to rest. It is that need for something tangible, that

“money for goods” transactional mindset, which leads people to feel like they’re leaving the

doctor’s office with nothing. And when a doctor’s salary, insurance reimbursement rates, and

number of clients depend upon patient satisfaction ratings, many doctors will surrender and

prescribe unnecessary antibiotics to their patients in order to keep said patients satisfied.

Restructuring the physician reimbursement system we’ve created so that rates of proper treatment

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matter more than patient satisfactions surveys (which are generally biased, poorly conceived, and

inappropriately written) would go a long way towards removing that incentive for doctors to

prescribe unnecessary treatment in general.

Now that antibiotic-resistant bacteria strains are widespread, understanding the role of

hospital workers in the spread or containment of MRSA is vital. From personal experience, I

have observed two institutional factors that suit the sociopolitical/economic perspective of

analysis. The economic pressures on hospitals often lead to administrators cutting staff to levels

that are too low to maintain proper infection control protocols. More importantly, those

economic pressures have lead to a system where individuals are hired for positions that should be

performed by trained professionals, instead of technicians who receive very little, highly

inadequate training in their job duties. Training for technician jobs often consists of a system

where the trainee is instructed on what to do, but not on why certain procedures are performed

and the consequences of not performing them. For example, trainees in Barnes-Jewish Hospital’s

diagnostic microbiology lab are taught to sterilize their workstations and to clean their tools

between specimens. What isn’t taught is the reasoning behind such actions: to prevent cross-

contamination and the growth of bacteria on other work surfaces. When employees aren’t given

that knowledge, or the importance of such actions isn't properly emphasized, employees will cut

corners. They won’t clean their workstations regularly if it doesn’t look dirty, regardless of what

might have gotten onto work surfaces when handling patient specimens. They won’t sterilize

their tools between specimens and cultures, which leads to faulty results for patients. This laxity

creates a perfect environment for different bacteria strains to mix and spread. It also enhances the

risk of patients’ getting false results, which leads to inappropriate or ineffective treatments,

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which also creates an opportunity for resistant strains to rise. It would be more expensive (in the

short run, at least) to hire properly educated personnel, or to spend more time and effort in

teaching untrained employees about the science behind their job duties, but raising the standards

for hospital employment could help decrease the rates of hospital-acquired infections.

The second institutional factor that I have observed is desensitization of hospital

employees to the very real risks of acquiring an antibiotic-resistant infection. When most hospital

employees start, they tend to be very strict about observing infection protocols (at least, the

protocols that protect them from infection; whether they are just as strict in following protocols

that protect patients is far more variable). But over time, assuming they don’t acquire an infection

from the hospital, employees often become more relaxed about following guidelines. Whether

consciously or subconsciously, employees often develop a mindset that infection protocols are

really just guidelines, not hard rules. Nurses’ scrubs are a perfect example of this: hospital nurses

are supposed to change into scrubs when they arrive at work, and change out of scrubs before

leaving. In practice, most hospital nurses wear the same scrubs when traveling to work, while at

work, and running errands on the way home from work. We know that MRSA spreads by

contact, so there’s a very good chance that MRSA bacteria is present on the scrubs of nurses

when they leave work (not to mention what might be on their scrubs when they arrive at work),

which means that there is a very good chance that those bacteria might come into contact with

other surfaces that are touched by other individuals. Bank counters, grocery store checkouts,

shopping carts, … The list of possible surfaces contaminated by a nurse’s post-work scrubs is

endless. This desensitization likely contributes to the increasing rates of community-acquired

MRSA infections.

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MRSA has become a regular part of our world, one which is likely impossible to

completely eliminate. All we can do now is attempt to minimize the chances of infection,

through better infection control protocols, tighter antibiotic control, improved healthcare access

and affordability, and greater awareness of the risks. This infection itself can be terrifying, but

what makes the situation worse is the knowledge that we, the medical community and the

general public, created this threat. If we can inadvertently create MRSA, what other horrors

might we unleash by accident? We’ve already seen a glimpse of the world that might come to be

if we don’t learn from MRSA. In January 2013, a man who was treated for a brain hemorrhage in

Vietnam was flown to Wellington Hospital in New Zealand. While he was there, he was found to

be carrying a bacteria strain known as KPC-Oxa 48, which completely rejected every single

antibiotic in use (McKenna, 2013). The infection resulted in the patient’s death. In less than one

hundred years, we went from being able to cure the infections that were once the most common

causes of death to seeing those same infections become a threat once again. If we don’t learn

from our mistakes, we will eventually enter a post-antibiotic era. Personally, that is something I

never want to see.

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References

Dantes, R., Mu, Y., Belflower, R., et al. (2013). National Burden of Invasive Methicillin-Resistant Staphylococcus aureus Infections, United States, 2011. JAMA Internal Medicine,

173(21). doi: 10.1001/jamainternmed.2013.10423.

Graham, P. L., Lin, S. X., & Larson, E. L. (2006) A U.S. Population-Based Survey of Staphylococcus aureus Colonization. Annals of Internal Medicine (144). doi:

10.7326/0003-4819-144-5-200603070-00006

Madigan, M. T., Martinko, J. M., Dunlap, P. V., & Clark, D. P. (2009). Brock Biology of Microorganisms. San Francisco, CA: Pearson Education, Inc.

McKenna, M. (2013, November 20). When we lose antibiotics, here’s everything else we’ll lose too. Wired. Retrieved from http://www.wired.com/2013/11/end-abx/

Mayo Clinic. (2012). MRSA infection: symptoms. Retrieved from: http://www.mayoclinic.org/diseases-conditions/mrsa/basics/symptoms/

Pastagia, M., Kleinman, L. C., Lacerda de la Cruz, E. G., & Jenkins, S.G. (2012). Predicting risk for death from MRSA bacteremia. Emerging Infectious Diseases, 18(7). doi: http://dx.doi.org/10.3201/

eid1807.101371

University of Chicago Medicine MRSA Research Center (2010). MRSA history timeline: 1959-2012. Retrieved from: http://mrsa-research-center.bsd.uchicago.edu/timeline.html