MRSA Decolonization Reduces Postdischarge Infection Risk

Jennifer Garcia

February 14, 2019

Decolonization following hospital discharge is better than hygiene education alone at decreasing the risk for infection with methicillin-resistant Staphylococcus aureus (MRSA) among patients colonized with MRSA (carriers).

"In the [current] trial, topical decolonization led to lower risks of infections and readmissions than hygiene education alone among patients after the transition from hospital to home and other care settings," write Susan S. Huang, MD, of the University of California Irvine School of Medicine, and colleagues. They reported their findings in an article published online today in the New England Journal of Medicine.

As part of a multicenter, randomized controlled trial, the researchers enrolled 2121 patients from 17 hospitals and seven nursing homes in southern California between January 10, 2011, and January 2, 2014. All participants tested positive for MRSA at the time of hospitalization or within the 30 days before or after.

Participants were followed for 12 months and were evaluated at months 1, 3, 6, and 9, with an exit interview conducted at month 12. Nares, throat, skin, and wounds (if present) were swabbed at all visits. Participants were financially incentivized to complete all follow-up visits and those in the decolonization group were provided free product.

Participants were randomized in a 1:1 ratio into 2 groups: the education only group or the decolonization plus education group. Both groups were provided with an educational binder about how MRSA is spread as well as recommendations for personal hygiene and environmental cleaning. Patients in the decolonization group were instructed to decolonize for 5 days twice a month for 6 months following hospital discharge.

The decolonization procedure "involved the use of 4% rinse-off chlorhexidine for daily bathing or showering, 0.12% chlorhexidine mouthwash twice daily, and 2% nasal mupirocin twice daily."

In the per-protocol population, MRSA infection occurred in 98 (9.2%) of 1063 participants in the education group compared with 67 (6.3%) of 1058 in the decolonization group. Hospitalization was required in 84.8% of the MRSA infections. Skin and soft-tissue infections and pneumonia were the most common infection types.

In addition, the researchers found that infection from any cause occurred in 23.7% of the participants in the education group vs 19.6% of those in the decolonization group. Hospitalization was required in 85.8% of patients with infection from any cause.

Overall, the risk of MRSA infection was significantly lower in the decolonization group than in the education group (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.52 - 0.96; P = .03) and resulted in a 29% lower risk for hospitalization due to a MRSA infection (HR, 0.71; 95% CI, 0.51 - 0.99).

In the as-treated analyses, Huang and colleagues found 44% fewer MRSA infections among participants in the decolonization group who adhered fully to the treatment protocol (HR, 0.56; 95% CI, 0.36 - 0.86). All adverse events were considered mild and occurred in 4.2% of the participants. Development of mupirocin resistance was low and comparable between both groups.

The authors also found that participants who fully adhered to the decontamination protocol "had fewer coexisting conditions, had fewer devices, required less bathing assistance, and were more likely to have MRSA infection (rather than asymptomatic colonization) at the time of enrollment than either participants in the education group or participants in the decolonization group who had lower levels of adherence."

An Important Clinical Intervention

When asked to comment on the significance of these study findings, Gonzalo Bearman, MD, chair of the Division of Infectious Diseases at Virginia Commonwealth University in Richmond, noted: "This is a well done and highly relevant study on an important clinical intervention."

Bearman notes that the decolonization protocol was effective and provides a significant benefit to "decrease the risk of not only invasive MRSA infection but also infection from other pathogens."

Despite efficacy and the feasibility of applying this intervention in a real world setting, Bearman cautions that, "[t]he selection pressure from ongoing mupirocin and chlorhexidine use may eventually select for isolates not susceptible to either of these agents".

Funding for this study was provided through grants from the Agency for Healthcare Research and Quality Healthcare-Associated Infections Program and the NIH Clinical and Translational Sciences Award program. Multiple authors have disclosed financial relationships with various biopharmaceutical companies including Stryker (Sage Products), Mölnlycke, 3M, Clorox, Xttrium Laboratories, and Medline. Bearman reports grants from several commercial entities, including Mölnlycke Healthcare and AO Orthopedic Foundation Grant.

N Eng J Med. Published online February 14, 2019. Abstract

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