Tatooing with MRSA

Question

Hello,

I would like to get another tattoo. I have MRSA (sputum result, no other swabs have been done), and there is no eradication planned.

I have already talked to my doctor about this plan. She was not very thrilled about it but said that the risk of infection was not higher than usual for me with this kind of procedure. This eliminated my doubts.

My question is geared in another direction – in a tattooing forum, I brought up the issue of hygiene in connection with MRSA. Many people were appalled and rejected it with the ludicrous reasoning to not even allow me in their studio.

Is there really a danger for the tattooer or the customer to get infected or colonized by me? In my opinion, this can practically be ruled out if the procedure is done in a properly sterile manner and with good hygienic practice. What do you think?

If the answer is yes, can I just leave my colonization unmentioned with a clear conscience in order to avoid panicked reactions?

Kind regards.

Answer

Dear questioner,

You are asking (1) about the risk of infection when getting a tattoo with a known MRSA colonization and (2) about the duty to indicate this MRSA colonization to the tattoo parlor regarding the risk of transmission to third parties.

A tattooing procedure constitutes a physical invasion with an (albeit minor) injury of the skin. This bears a certain risk of infection which depends on several factors (e.g. hygiene conditions during and after the procedure, wound healing, condition of the individual’s immune system and germ colonization). The average risk of infection when paying attention to the general hygienic rules is low but cannot be ruled out completely, of course. Eventually, you will have to weigh your choices and it remains your decision whether you want to get a tattoo or not (written consent and information about risks is necessary).

To help you with your decision:

Ad (1) Staphylococcus aureus is known to be a common infectious agent particularly of wound infections. MRSA is a staph aureus with a special resistance to antibiotics that are usually effective (e.g. oxacillin or cephalosporin). Therapeutic measures are therefore considerably limited in case of an MRSA infection. Regularly sensible staph aureus strains (MSSA) occur rather often in the population as colonizers of the skin and mucous membranes; MRSA, on the other hand, only very rarely so.

In case of colonization, wounds can get contaminated and infected by a so-called smear infection. It is particularly possible to pass on staph aureus via contaminated instruments. If the tattooer also carries staph aureus, they can pass it on to their customers directly or indirectly as well by improper work practices, of course. If the customer is a germ carrier, spreading the agent into the “tattooing wound” is easily conceivable as well, of course. Since the germ carrier status is usually unknown, basic hygiene rules should be followed to avoid infections.

Very rarely, there are staph aureus variants with the ability (“virulence”) to trigger severe wound infections. Among the germs belonging in this group are the so-called CA-MRSA (“community acquired” MRSA), which are extremely resistant as well as particularly virulent. In the United States, CA-MRSA infections have been reported repeatedly in connection with tattooing [1]. A CA-MRSA carrier would therefore have to be advised against getting a tattoo. CA-MRSA has also been described in Germany, though only rarely so far, which means that a CA-MRSA presence is rather unlikely in your case. Patients with wound healing disorders (e.g. diabetes mellitus) should also be discouraged from getting a tattoo. You should talk about particular risks with your treating physician as appropriate.

Conclusion: during the tattooing procedure, infections can largely be prevented by following appropriate hygiene rules (gloves; disinfection of instruments, skin and surfaces; etc.). Generally, the risk of transmission is not higher with MRSA than with MSSA. As a rule, from an epidemiological perspective, MSSA might even occur more often e.g. in the tattooer’s or the customers’ nasal mucous membranes. An increased occurrence in the context of tattooing has not been documented, except for CA-MRSA. When sticking to all hygienic rules, the risk of infection is calculably low but cannot be ruled out.

With CF (higher density of agents, cough) the relative risk of transmission may well be higher than with “healthy” MRSA carriers. In case of additional colonization of the skin, the risk of contamination of the “tattooing wound” has to be considered higher than with MRSA colonization of the upper respiratory tracts only. Even after the tattooing procedure, there remains a risk of infection, at least until the wound has healed completely. Therefore, appropriate (hand) hygiene measures need to be applied consistently. Like your doctor, I am “not thrilled” either and would therefore rather discourage you from getting a tattoo – though not categorically so (see additional comment below).

Ad (2) Concerning the risk of infection for customers, then, hygiene management in the tattoo parlor is of central importance. [Translator’s comment: information on German legal regulations and requirements concerning infections and hygienic measures in tattoo parlors has been omitted in the translation.]

A risk of infection particularly for the following customers cannot be ruled out completely. In your case, this could be minimized by wearing a protective face mask during the procedure and by consistent surface disinfection after the procedure, as well as by your being scheduled as the last customer of the day, for instance. Similar measures are recommended for the management of MRSA carriers in medical institutions. Lastly, a tattoo parlor is a kind of “treatment facility” as well, and I would therefore consider a tightened hygiene standard as absolutely reasonable.

[Translator’s comment: information on benefit restrictions of German health insurances has been omitted.]

[1] Methicillin-resistant Staphylococcus aureus skin infections among tattoo recipients - Ohio, Kentucky, and Vermont, 2004-2005. MMWR Morb Mortal Wkly Rep. 2006 Jun 23;55(24):677-9.

Kind regards
M. Hogardt

07.09.2010