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JBIeradicatingmrsawithmupirocin.pdf

MRSA: DECOLONIZATION Search date 28/01/2021

Author Madhava Sai Sivapuram MBBS Student

Publication date 03/05/2021

Question What is the best available evidence regarding the effectiveness of strategies for eradicating methicillin- resistant Staphylococcus aureus carriage in non-intensive care settings?

Clinical Bottom Line Colonization is an important process in the pathogenesis of Staphylococcus aureus (S. aureus) infection.1

Approximately 20% of the general population is persistently colonized with S. aureus, most frequently in the anterior nares and another 30% of the general population is intermittently colonized.1 Methicillin-resistant S. aureus (MRSA) has become endemic in healthcare settings worldwide, with up to 70% of invasive S. aureus infections having drug resistance, and most patients who develop drug-resistant S. aureus infection will have been colonized prior to infection.1

A systematic review with meta-analyses assessed the effectiveness of different approaches for eradicating MRSA carriage. The following was reported:1 (Level 1)

Medicines for eradicating MRSA carriage included topically applied mupirocin, bacitracin nasal ointment, tea tree oil, systemic (orally administered) antibiotics (tetracyclines, fusidic acid, macrolides, ciprofloxacin, rifampin, and trimethoprim-sulfamethoxazole.

Mupirocin eradicated MRSA carriage 11 times more effectively than no treatment, with successful eradication in 94% of carriers one week after treatment.

Bacitracin nasal ointment eradicated carriage in 29% of MRSA carriers at one week after treatment.

The development of drug resistance during treatment was reported in 1% and 9% of patients receiving mupirocin and oral antibiotics, respectively.

Short-term nasal application of mupirocin was the most effective treatment for eradicating MRSA carriage, with an estimated success rate of 90% one week after treatment and 60% after a longer follow-up period (two to 52 weeks).

In patients with factors that were associated with treatment failure (e.g., mupirocin- resistant strains), systemic eradication treatment (e.g., rifampin administered in combination with another oral antibiotic), in addition to mupirocin nasal ointment, was the treatment of choice.

A prospective randomized controlled trial (RCT) estimated the effectiveness of isolation and decolonization measures in reducing MRSA transmission in hospital general wards. The combined effect of isolation and decolonization with mupirocin was estimated to reduce transmission by 64%. Undetected MRSA-positive patients were estimated to be the source of 75% of total transmission events. Isolation measures combined with decolonization treatment were strongly associated with a reduction in MRSA transmission in hospital general wards.2 (Level 1)

An RCT found that planned intervention of screening and decolonization with nasal mupirocin and chlorhexidine (CHG) bathing and enhanced environmental cleaning with bleach every four months was successful at lowering MRSA colonization.3 (Level 1)

An RCT evaluated two MRSA eradication protocols on patients who were pharyngeal carriers of MRSA. One treatment group received oral rifampicin and either clindamycin or trimethoprim/sulfamethoxazole (SXT) for seven days in combination with nasal mupirocin. Patients in the other group were treated with nasal mupirocin only. Both groups followed a hygiene protocol including CHG washing twice weekly. At six months following treatment, 61% of the patients who received combined systemic and topical treatment were negative for MRSA compared with 13% of patients in the topical treatment-only group. Of the households, 50% of the households in the combined systemic and topical treatment group were negative six months after treatment compared with 10% of the households in the topical treatment group.4 (Level 1)

A multicentre RCT examined the decolonization to reduce post-discharge infection risk among MRSA carriers. The intervention group received CHG mouthwash, baths, or showers with CHG, and nasal mupirocin for five days twice per month for six months and the control group received only post-discharge hygiene education. The authors concluded that post-discharge MRSA decolonization with CHG and mupirocin led to a 30% lower risk of MRSA infection than education alone.5 (Level 1)

A clinical guideline recommended that targeted interventions screen to detect asymptomatic carriage and use patient isolation, often combined with decolonization therapy, to reduce MRSA carriage. The nasal decolonization with mupirocin was also recommended as a prophylaxis before an operation.6 (Level 5)

Characteristics Of The Evidence This summary is based on a structured search of the literature and selected evidence-based health care databases. Evidence in this summary is from:

A systematic review with meta-analyses with 23 RCTs including 2,024 participants.1

A prospective cluster-RCT in a tertiary hospital with 12 general wards and 14,035 patient episodes.2

A prospective, cluster RCT involving three long-term care facilities with 4,424 participants.3

An open RCT involving a total of 52 eligible patients in 42 different households.4

A multi-centre RCT involving 2,121 participants.5

An evidence-based guideline.6

Best Practice Recommendations Eradication of S. aureus carriage may prevent MRSA infection and transmission. (Grade A)

Short-term nasal application of mupirocin is recommended as an effective treatment for eradicating MRSA carriage. (Grade A)

In patients with factors that are associated with treatment failure, oral rifampin is recommended. (Grade A)

The addition of systemic treatment to topical treatment may be beneficial in successfully decolonizing the throat. (Grade B)

References Ammerlaan HS, Kluytmans JA, Wertheim HF, Nouwen JL, Bonten MJ. Eradication of methicillin-resistant Staphylococcus aureus 1. carriage: a systematic review. Clin Infect Dis. 2009;48(7):922-30.

Worby CJ, Jeyaratnam D, Robotham JV, Kypraios T, O'Neill PD, De Angelis D, et al. Estimating the effectiveness of isolation and 2. decolonization measures in reducing transmission of methicillin-resistant Staphylococcus aureus in hospital general wards. Am J Epidemiol. 2013;177(11):1306-13.

Schora DM, Boehm S, Das S, Patel PA, O’Brien J, Hines C, et al. Impact of detection, education, research and decolonisation 3. without isolation in long-term care (DERAIL) on methicillin-resistant Staphylococcus aureus colonisation and transmission at 3 long- term care facilities. Am J Infect Control. 2014;42 (10 Suppl):S269-73.

Lindgren AK, Nilsson AC, Åkesson P, Gustafsson E, Melander E. Eradication of methicillin-resistant Staphylococcus aureus 4. (MRSA) throat carriage: a randomised trial comparing topical treatment with rifampicin-based systemic therapy. Int J Antimicrob Agents. 2018;51(4):642-5.

Huang SS, Singh R, McKinnell JA, Park S, Gombosev A, Eells SJ, Gillen DL, et al. Decolonization to reduce postdischarge infection 5. risk among MRSA carriers. N Engl J Med. 2019;380(7):638-650.

Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al. EPIC3: National evidence-based guidelines for preventing 6. healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86 Suppl 1:S1-70.

The author declares no conflicts of interest in accordance with International Committee of Medical Journal Editors (ICMJE)standards.

How to cite: Sivapuram, M. Evidence Summary. MRSA: Decolonization. The JBI EBP Database. 2021; JBI-ES-1591-1.

For details on the method for development see Munn Z, Lockwood C, Moola S. The development and use of evidence summaries for point of care information systems: A streamlined rapid review approach. Worldviews Evid Based Nurs. 2015;12(3):131-8.

Note: The information contained in this Evidence Summary must only be used by people who have the appropriate expertise in the field to which the information relates. The applicability of any information must be established before relying on it. While care has been taken to ensure that this Evidence Summary summarizes available research and expert consensus, any loss, damage, cost or expense or liability suffered or incurred as a result of reliance on this information (whether arising in contract, negligence, or otherwise) is, to the extent permitted by law, excluded.