When what appear to be insect or spider bites crop up on the bodies of inmates at a correctional facility, how does the healthcare staff respond?  In years past, they probably treated the inmates for minor skin irritations and sent them on their way.  With methicillin-resistant Staphylococcus aureus (MRSA) spreading through communities nationwide, however, correctional health care providers are taking a much closer look at inmates' skin ailments.

MRSA infections are caused by Staphylococcus aureus bacteria, commonly referred to as staph, that have become resistant to various antibiotics.  Staph bacteria are typically carried on the skin or in the nose of healthy people.  Occasionally, these bacteria can cause infections, both minor ones, like pimples and boils, and more serious infections that require antibiotics to treat.  Through the years, however, staph bacteria have become resistant to certain antibiotics, resulting in a form of bacteria known as MRSA.

Because MRSA is commonly spread through direct physical contact with infected people or indirect contact with items like towels, sheets, clothes and sports equipment, environments where people are confined in close quarters are conducive to the spread of the bacteria.  Los Angeles County learned this lesson in 2001, when a mysterious skin infection started to spread through its jail system.

"We're a reflection of the community," said Martha Tadesse, a public health nurse in the communicable disease unit of the Los Angeles County Sheriff's Department Medical Services Bureau.  If people in the community have MRSA, it spreads into the jails, she said.

Investigating Complaints

The MRSA outbreak began with inmates telling health care staff that they had insect or spider bites, claims the medical care providers began to investigate.

"In the case with any patient, they present a complaint," said Dr. John Clark, chief medical officer for the Los Angeles County Sheriff's Department.  "In this instance, the patient presented with complaints of spider or insect bites," he added.  "That was the initial clue, so to speak."

These complaints prompted the county to begin taking cultures from inmates to determine what was causing their skin lesions, Clark said.

"When you do a culture, you make an attempt to identify what the bacteria is," Clark said.  MRSA was not identified at first, however, because the lab results were not always being evaluated by the same physicians who ordered the tests.
 
With no apparent clues from the cultures and the number of complaints of bites increasing over time, the medical staff teamed up with custody personnel and the county's public health department to examine the jails' housing units and laundry facilities.  They found no evidence of insect or spider infestation problems.

Identifying and Treating MRSA

In April 2002, interviews with inmates did provide some insight into the problem, however.

"We discovered during some of the interviews we did with inmates that there were some occurrences where they were popping pimples or boils on each other," Clark said.  Also, some were sharing razors and other instruments, he said, practices that could quickly spread bacteria like MRSA.

"We went back and reviewed all of the cultures we had done," Clark said.  "That was when we realized that we had close to 75 percent positive MRSA results."

Once MRSA was detected, the custody staff was notified immediately and treatment began for those inmates with skin lesions.

"We developed a treatment regime which would allow us to treat patients with antibiotics," Clark said.

Because MRSA bacteria are resistant to certain antibiotics, particularly common penicillin-related antibiotics, Los Angeles County medical staff used Bactrium and Rifampin to treat MRSA infections.

Also, Clark and his medical team, as part of their new treatment protocol, decided that when inmates present with signs of skin irritations similar to insect or spider bites, they would begin treatment for MRSA automatically.

"We immediately took the cultures and went ahead and started the antibiotics," Clark said.

Aside from starting treatment for inmates with MRSA infections, the county also began educating its incarcerated population and corrections staff about the bacteria and how it is spread.

"We used all of the educational modalities we had available to us," Clark said.  Inmates were provided with MRSA literature and were shown videos about how to prevent the spread of the bacteria, he added.

Making Changes to Deal with MRSA

In addition to developing a treatment protocol and educating inmates and staff about MRSA, some changes were implemented throughout the Los Angeles County jail system as a result of the difficulties the county experienced in identifying MRSA.

Because the bacteria was not detected the first time the inmates' cultures were evaluated due to inmates moving around in the system and different doctors checking lab results, all cultures are now reviewed by the medical services communicable disease unit.

Also, a MRSA task force was formed to make recommendations about how to handle MRSA infections and to monitor the county's progress in meeting those guidelines.  

Among the task force's recommendations were encouraging inmates to report skin lesions, culturing all skin infections, providing wound care each day and enabling good hygiene for inmates.

Clark agrees with the task force that hygiene is centrally important in the county's battle with MRSA.

"Wash your hands," said Clark.  "[It's] the most important thing."

Also, inmates must have access to basic necessities like water, showers and toilet paper and be encouraged to shower each day, Clark said.

Although the percentage of MRSA-positive cultures has dropped from 75 percent to 50 percent in Los Angeles County since the MRSA outbreak, Clark and the medical staff there will continue to follow the treatment protocol to decrease those numbers, he said.

"Certainly [MRSA] is something that all practitioners as well as all people in institutions where you have close contact need to be on the look-out for," Clark said.

Resources:

To contact the Los Angeles County Medical Services Bureau, call (213) 893-5455