Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Methicillin Resistant Staphylococcus Aureus (MRSA)


Related Terms

  • S. aureus
  • Staph Infections
  • Staphylococcal Infections
  • Staphylococcus aureus

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Infectious Disease Internist
  • Internal Medicine Physician
  • Nephrologist
  • Pulmonologist
  • Urologist

Comorbid Conditions

Factors Influencing Duration

The source and extent of the infection, age and health status of the individual, immune status, timeliness of treatment after MRSA is diagnosed, and response to treatment, will influence duration. The development of complications, especially toxic shock syndrome or organ failure, may increase length of disability. The need to surgically remove and replace implanted devices or prostheses may extend hospitalization, recovery time, and length of disability.

Medical Codes

ICD-9-CM:
041.11 - Methicillin Susceptible Staphylococcus Aureus; MSSA; Staphylococcus aureus NOS
041.12 - Methicillin Resistant Staphylococcus Aureus (MRSA)
V02.53 - Carrier or Suspected Carrier of Infectious Diseases; Methicillin Susceptible Staphylococcus Aureus
V02.54 - Carrier or Suspected Carrier of Infectious Diseases; Methicillin Resistant Staphylococcus Aureus

Overview

Methicillin-resistant Staphylococcus aureus (MRSA) is a specific strain of S. aureus bacteria that is resistant to methicillin, a penicillin-like antibiotic; it often is resistant to other antibiotics as well. Antibiotic resistant organisms do not die as intended when exposed to an antibiotic that normally would be expected to kill them. MRSA is called a "superbug" because of its strong antibiotic resistance and its ability to complicate treatment of staphylococcal infections.

Staphylococci are gram-positive organisms; that is, they test positive when a sample of infected material is cultured and stained with Gram stain. They are also aerobic organisms, indicating that they are dependent on oxygen to fuel their metabolism. Staphylococcal organisms are responsible for causing a variety of diseases and conditions, including abscesses, gastroenteritis, endocarditis, hospital-acquired bacteremia associated with the use of catheters and IV equipment, skin infections, wound and burn infections, pneumonia, and meningitis. Staphylococci also produce bacterial toxins (i.e., exotoxins, enterotoxins, exfoliative toxins, toxic-shock-syndrome toxin or TSST-1) that can cause both local infection and serious systemic illness that may result in shock (toxic shock syndrome), organ failure, and death.

MRSA has two sub-types based on the origins of the infection. Hospital-acquired MRSA (HA-MRSA) is found in hospitalized individuals and in those who have had recent surgery or have been in a hospital or other healthcare facility (e.g., rehabilitation or long-term care facilities) within a year prior to developing infection. Community-acquired MRSA (CA-MRSA) is found in relatively healthy individuals who have not recently been in a healthcare facility. Infection spreads within the community among individuals who share personal items (e.g., drinking glasses, utensils, towels, razors) or sports equipment, or who are enclosed for extended periods within the same physical space (e.g., schools or daycare facilities).

Colonies of S. aureus are found in the nose, armpits, groin, and on the skin of about 20% to 30% of healthy adults; about 80% of all people may be colonized with the organism at various times but not consistently (Herchline). Hospitalized individuals, hospital personnel, and healthcare workers generally have higher rates of S. aureus colonization (Herchline). Although the presence of the organism does not result in disease in the majority of individuals, it may more easily overwhelm the immune system and cause infection in those who have an existing skin injury, other significant injury, chronic illness such as diabetes, or whose immune system function is compromised (immunosuppression). MRSA is the most pathogenic of all staphylococci, most often causing skin infections, pneumonia, infection of the heart valves (endocarditis), and bone marrow infection (osteomyelitis). S. aureus also has the ability to clot (coagulate) blood (coagulase-positive staphylococci), contributing to its virulence and antibiotic resistance.

Incidence and Prevalence: From 20% to 30% of individuals are colonized with S. aureus consistently, and up to 80% are colonized at some time (Herchline). Over half (59%) develop skin and soft-tissue infection, and more serious systemic infection develops in about 94,000 individuals annually (Davis). HA-MRSA affects about 64% of all individuals in intensive care units (ICU); another 126,000 individuals are admitted to hospitals with CA-MRSA (Davis).

MRSA is found worldwide. Estimates of colonization range from 11% to 40% in specific populations; more than 50% of these are estimated to develop infection (Davis).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk of MRSA infection is highest in individuals with chronic lung disease (e.g., chronic bronchitis, emphysema, cystic fibrosis), influenza, leukemia, malignant tumors, transplanted organs, implanted prostheses or devices (e.g., prosthetic heart valves), burns, chronic skin disorders (e.g., psoriasis, eczema), diabetes, surgical incisions that have not yet healed, urinary catheters, or indwelling intravenous catheters. Individuals undergoing kidney dialysis are at increased risk as well. Those who are immunocompromised as a result of receiving chemotherapy, immunosuppressant drugs, radiation, or corticosteroids also are at increased risk. Newborn infants and mothers who are nursing infants are particularly susceptible to staphylococcal infections. Groups within the community who are at increased risk for staphylococcal infection include athletes who share equipment, military personnel, hospital personnel, healthcare workers, children in daycare facilities, and individuals who get tattoos. Elderly individuals have increased risk due to the prevalence of chronic disease and immune system dysfunction.

Source: Medical Disability Advisor



Diagnosis

History: Local skin infections caused by MRSA may produce a red, warm, swollen area at the infection site; an abscess may form if the area is not treated early. As the infection progresses, the area may become painful and the individual may report a fever. Pus (purulent discharge) may be present in the sore (as in boils), under the skin (as in abscesses), or draining from the sore (as in carbuncles, a stye in the eyelid, or impetigo blisters on the skin surface). More serious systemic staphylococcal infection in a hospitalized individual may produce chills and fever, low blood pressure, cough, chest pain, general malaise, headache, muscle aches, and rash. The individual may complain of fatigue and shortness of breath. Medication history is important in determining if the individual is already taking antibiotics with no apparent results. A history of recent hospitalization or surgery may be reported. History of acute or chronic illness, recent surgery, implanted devices or prostheses, and recent pregnancy and childbirth, also may be reported.

Physical exam: Signs of infection may include localized skin infections with redness and warmth (erythema), swelling (edema), and the presence of purulent discharge. Draining sinus tracts may be noted. The individual is examined for any open wounds from either injury or recent surgery. A primary site of infection may not be found in a hospitalized patient. Fever may be present. Blood pressure may be low. Confusion or mental deterioration may be apparent. Heart irregularities (e.g., regurgitant murmur) and lung sounds suggestive of pneumonia may be noted on examination with a stethoscope (auscultation). The individual will be evaluated for indications of organ failure. An all-over reddish or sunburned appearance of the skin (diffuse erythroderma) with high fever may indicate systemic infection and impending toxic shock syndrome.

Tests: The most important diagnostic test is to isolate and identify the bacterium causing the infection. This is done by performing a culture of the purulent material at the site of localized infection or, in systemic infection, culturing blood and urine samples, swabs of drainage in the nose and throat, material raised on coughing (sputum), and bone marrow or joint fluid removed by needle aspiration. Once the infective organism is identified, sensitivity studies are done to determine the most effective antibiotic, as well as those to which the organism is resistant. Methicillin usually is included in sensitivity testing to help confirm MRSA. Culture and sensitivity testing is a lengthy process involving the growth of bacterial colonies on special media over several days until results can be read by a bacteriologist. Finding an appropriate antibiotic may take even more time if MRSA is the causative organism.

If MRSA is isolated or suspected, a coagulase test will be done to evaluate the ability of S. aureus to produce the coagulase enzyme definitive of MRSA, confirming the diagnosis. If systemic infection is present, other laboratory tests often include a complete blood count (CBC) with differential to examine white cell response by the immune system; a chemistry panel including electrolytes, liver and kidney function tests, and cardiac enzymes; C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to evaluate inflammation level; and urinalysis and 24-hour urine tests to evaluate kidney function and fluid balance. A chest x-ray may be done to assess for pneumonia. In individuals with high-grade MRSA bacteremia with no definitive source of infection or in cases of suspected catheter-related bacteremia, transthoracic echocardiography (transesophageal echocardiography or TEE) may be performed.

Source: Medical Disability Advisor



Treatment

Antibiotic therapy is the primary treatment for staphylococcal infection even though it may be complicated by antibiotic resistance. Local infection by MRSA may require only draining the abscess and giving an antibiotic that has been shown on culture and sensitivity studies to be effective against the MRSA bacterium causing the infection. Although serious MRSA infections are becoming more difficult to treat with antibiotics, some antibiotics that have been shown to be effective against antibiotic-resistant S. aureus include clindamycin, daptomycin, doxycycline, linezolid, minocycline, tetracycline, trimethoprim-sulfamethoxazole, and vancomycin. The full course of antibiotics prescribed must be taken since discontinuing the drug may lead to recurrence of the infection. If the individual has been receiving immunosuppressant therapy, it may be discontinued until the infection has responded to treatment.

Treatment for systemic infection, such as blood poisoning (septicemia), pneumonia, or bacteremia, may include round-the-clock intravenous antibiotics, intravenous fluid administration, kidney dialysis if the infection causes kidney failure, and oxygen, as needed. Infected prosthetics, such as heart valves or artificial limbs, grafts, or pacemakers, may be surgically removed and replaced. Surgical intervention also may be needed to treat joint infections, postoperative abscesses, and osteomyelitis. Antibiotic therapy is administered before, during, and after surgical procedures. While awaiting culture results to confirm MRSA, the individual may be started on a known anti-MRSA agent until the sensitivity test results are available. Endocarditis usually requires a prolonged period of antibiotic treatment; duration of antibiotic treatment for other infections varies according to the type and extent of the infection. Combinations of antibiotics may be used to address all possible pathogens causing the infection.
Hospitalized patients with MRSA usually are isolated from other patients to reduce the risk of spreading the infection. Hospital personnel and visitors are required to follow sterile procedures before and after contact with a patient in isolation.

Source: Medical Disability Advisor



Prognosis

The prognosis for MRSA infection varies depending on the extent of the infection, the health status of the individual, and whether an appropriate antibiotic treatment is found before the infection overwhelms the immune system. Individuals in relatively good health before MRSA infection usually recover. In other individuals, the earlier treatment is begun, the better the prognosis. The mortality for MRSA is greater than that for HIV infection, accounting for 19,000 deaths a year in the US; about 86% of deaths are due to HA-MRSA, and 14% are due to CA-MRSA (Davis). Pneumonia and septicemia are the most frequent causes of death from MRSA infection and carry a mortality rate of about 20% (Davis). More than 80% of S. aureus bacteremia that goes untreated results in death, and the mortality rate for staphylococcal toxic shock syndrome is 3% to 5% in those who develop this complication (Herchline).

Source: Medical Disability Advisor



Complications

Recurrence is a frequent complication (21%) in immunocompromised individuals such as those with HIV or a weakened condition due to chronic illness such as diabetes; recurrence in skin infections is higher (41%) (Davis). Some individuals may be MRSA carriers for up to 30 months. Rapidly spreading S. aureus infections may lead to septicemia, cellulitis, endocarditis, pneumonia, and toxic shock syndrome. A frequent complication of MRSA is the need to surgically remove and replace implanted devices or prostheses, prolonging hospital stays and recovery time. Risk of complications is reduced with early recognition and treatment of the infection and strict hygiene practices.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

If MRSA infection resolves without complications, no work restrictions or accommodations usually are necessary. Complications such as septicemia, toxic shock, or surgery to remove and replace implanted heart valves or prostheses may require hospitalization with intensive treatment followed by an extended recovery period that necessitates prolonged time off from work. Any permanent organ damage may require restrictions or accommodations. Heart damage may reduce the number of hours an individual can work and limit work duties to more sedentary ones. Kidney damage may require the individual to work reduced hours to allow dialysis for treatment.

Source: Medical Disability Advisor



Regarding diagnosis

Regarding diagnosis:
  • Did individual have fever and chills? Signs of local infection such as redness, warmth, and purulent material under the skin or draining from an open wound? Other signs consistent with systemic infection?
  • Was there an open wound from injury or history of recent surgery? Does individual have an implanted device, prothesis, IV line, or urinary catheter?
  • Were heart irregularities or lung sounds suggestive of pneumonia noted on physical examination?
  • Does individual have chronic illness such as diabetes or COPD? Cancer? A history of recent hospitalization or surgery?
  • Is individual a nursing mother?
  • Is individual receiving immunosuppressant therapy (e.g., chemotherapy, radiation, corticosteroids)?
  • Does individual have HIV infection/AIDS or other immune system disease?
  • Was a culture done of wound drainage, sinus drainage, sputum, blood or urine sample, aspirated spinal fluid or bone marrow? Was it positive for S. aureus?
  • Did sensitivity results indicate MRSA? Was appropriate antibiotic therapy determined?
  • Have appropriate diagnostic tests been done to assess systemic infection, including CBC, chemistry panel, CRP, ESR, and urine tests? Was chest x-ray done? TEE?
  • Have conditions with similar symptoms been ruled out?
  • Is this a case of HA-MRSA or CA-MRSA?

Regarding treatment:

  • Was individual hospitalized at the time of diagnosis?
  • Was local infection or abscess drained of infected material?
  • Were antibiotics administered immediately, before culture and sensitivity results were available?
  • Was the antibiotic drug changed after sensitivity results revealed a more effective agent? Was a combination of antibiotics given?
  • Was it necessary to surgically remove and replace an implanted device, heart valve, or prosthesis?
  • If individual was receiving immunosuppressant therapy, was it discontinued during treatment for infection?

Regarding prognosis:

  • Is individual older than age 65?
  • Does individual have poor health status due to chronic or debilitating disease? Is it likely to affect recovery?
  • Did individual require surgery to remove and replace a device or prosthesis? Was hospital stay increased? Is recovery period increased?
  • Have complications developed, such as septicemia, cellulitis, endocarditis, pneumonia, and toxic shock syndrome?
  • Did individual have organ failure as a result of systemic infection?
  • How are complications being treated? Was hospital stay increased? Is recovery period increased?
  • Has infection recurred since treatment was completed?
  • Is employer able to accommodate any restrictions?

Source: Medical Disability Advisor



References

Cited

Davis, Charles. "MRSA Infection." eMedicine Health. Eds. Melissa C. Stoppler, et al. 9 Jan. 2009. WebMD, LLC. 19 Oct. 2009 <http://www.emedicinehealth.com/mrsa_infection/article_em.htm>.

Herchline, Thomas. "Staphylococcal Infections." eMedicine. Eds. Klaus-Dieter Lessnau, et al. 20 Aug. 2008. Medscape. 19 Oct. 2009 <http://emedicine.medscape.com/article/228816-overview>.

General

Archer, G. L. "Staphylococcus Infections." Cecil Medicine. Eds. Lee Goldman, et al. 23rd ed. Saunders Elsevier, 2007. MD Consult. Elsevier, Inc. 19 Oct. 2009 <http://mdconsult.com>.

Source: Medical Disability Advisor






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