Guest Author – Susan Huang, M.D., M.P.H
Lead author of the REDUCE MRSA study
Associate Professor, UC Irvine School of Medicine
Medical Director of Epidemiology and Infection Prevention, UC Irvine Health
For years, we have searched for new strategies to turn the tide against antibiotic-resistant pathogens in healthcare facilities.
In particular, Methicillin-resistant Staphylococcus aureus (or MRSA) has become a common threat to patients. MRSA is spreading in both community and healthcare settings and can cause severe disease, particularly among patients in intensive care units. Patients who have MRSA on their bodies are at increased risk of developing a MRSA infection and healthcare personnel can spread the bacteria from them to other patients.
Today, I would like to share with you the exciting results from a study known as the REDUCE MRSA trial. The study, published in today’s New England Journal of Medicine, was conducted at 43 hospitals within the Hospital Corporation of America health system. The REDUCE MRSA trial was carried out by a multidisciplinary team from the University of California, Irvine; Harvard Pilgrim Health Care Institute; Rush University; Stroger Hospital of Cook County; Washington University in St. Louis; HCA; and CDC. The trial was federally funded by and conducted through research programs at the Agency for Healthcare Research and Quality (AHRQ) and the CDC’s Prevention Epicenters program.
The intervention involved nearly 75,000 patients and more than 280,000 patient days in 74 adult ICUs located in 16 states. The study randomized hospitals to the following three prevention strategies:
- Usual Care: Screening all ICU patients and isolating MRSA carriers
- Targeted Decolonization: Screening all ICU patients and isolating and decolonizing MRSA carriers with chlorhexidine baths and nasal mupirocin ointment
- Universal Decolonization: Discontinuing screening, adding decolonization of all ICU patients with chlorhexidine baths and nasal mupirocin ointment. Known MRSA carriers continued to be isolated.
The REDUCE MRSA trial showed that universal decolonization was the most effective and also the simplest strategy. It reduced MRSA clinical cultures by 37 percent. In addition, bloodstream infections due to all pathogens were decreased by 44 percent.
These benefits due to universal decolonization are notable for several reasons:
- Benefit extends to all pathogens, not just MRSA: Universal decolonization greatly reduces serious bloodstream infections due to all pathogens.
- Achievable by usual hospital quality improvement infrastructure: This pragmatic trial relied upon each hospital’s usual personnel and processes for practice change. There were no on-site study personnel at any of the hospitals.
- Effective in community hospitals: This intervention is relevant to the majority of US hospitals.
As universal decolonization in adult ICUs is adopted by hospitals, including the 160+ hospitals in the HCA health system, we will need to monitor the potential emergence of antibiotic resistance as a result of broad use of chlorhexidine and mupirocin. Mupirocin resistance has been reported in some, but not all MRSA decolonization studies, and chlorhexidine resistance is currently rare in the US, but surveillance programs will be important for monitoring the emergence of resistance.
Universal decolonization obviates the need for surveillance cultures and reduces the use of contact precautions. CDC is looking at the results of this trial and other studies on chlorhexidine bathing to determine how findings should inform CDC infection prevention recommendations.
The REDUCE MRSA Team extends its immense gratitude to the participating HCA hospitals -without their deep dedication to patient safety and infection prevention, this trial and its findings would not have been possible.
To read the entire study: http://www.nejm.org/doi/full/10.1056/NEJMoa1207290