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Making Infection Prevention “Simple”

Categories: Antimicrobial Resistance, Healthcare-associated infections, MRSA

Susan Huang, MD, MPH

Susan Huang, MD, MPH

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

Public Comments

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  1. AUTHOR COMMENT June 7, 2013 at 11:33 am ET  -   .

    Thanks for your thoughtful comments, as always.

    Re: contact precautions vs standard precautions
    All arms of the REDUCE MRSA trial applied contact precautions in the manner that is currently recommended by the CDC – meaning, if a patient was known to harbor a multi-drug resistant organism (e.g. MRSA) or have other reasons for contact precautions (e.g. uncontained secretions), contact precautions were applied. Thus, the insight that this study can provide is more related to screening than to the utility of contact precautions. In the setting of universal decolonization, cessation of screening and thus cessation of the fraction of contact precautions solely attributable to screening, still results in marked reductions in MRSA clinical cultures and ICU bloodstream infections and is a highly effective strategy.
    Unfortunately, this study provides no insight on whether the reduction in MRSA clinical cultures or ICU bloodstream infections would have been greater had universal contact precautions been used nor does it provide insight on whether the reductions would have been similar had all contact precautions been discontinued during universal decolonization. That debate persists.

    Re: high-level resistance to mupirocin
    This is a very important and commonly-raised question with pros and cons to be weighed. As such, I will provide my personal take on some of the pros and cons specific to mupirocin (will not address chlorhexidine resistance, which is rare, but arguably subject to emergence of resistance as well). This list is not exhaustive, but my personal opinion is that the pros would outweigh the cons in many if not most hospitals.

    Pro

    While there is a risk for emerging resistance, the impact that universal decolonization has on MRSA clinical cultures and reduction in ICU-associated bloodstream infections is large and hard to achieve by other means. Thus, the risk of emerging resistance should not lead us to inaction to prevent a large number of infections in high risk patients. If the impact of universal decolonization were small, you could imagine that hospitals could have their choice of a range of interventions to achieve that reduction. In this study, the comparison group is the proactive US gold standard, so these reductions are rather remarkable after what the nation has already achieved.

    When you consider the combination of MRSA and MSSA together I am convinced Staphylococcus aureus remains the #1 healthcare-associated pathogen in the US, and mupirocin helps eradicate the main reservoir (the nose) for this important pathogen. Use should be considered for (and restricted to) highly vulnerable populations such as ICU patients. Universal use in such patients is better than targeted use of mupirocin which is heavily dependent on insensitive one-time nares screens that miss many MRSA carriers as well as MSSA carriers who are also at higher risk of S. aureus infections.

    Currently, high-level mupirocin resistance is relatively small and data on emergence of resistance during broad use of mupirocin is conflicting (some show emergence, some do not, and some show emergence without any use of mupirocin). We will have to monitor, but a highly effective intervention should not be ignored.

    If resistance emerges, we will lose a topical agent, not one used to treat disease

    If resistance emerges, there are other effective agents that could be used to decolonize in place of mupirocin.

    Con

    The current trials are unable to disentangle the impact of universal chlorhexidine vs universal chlorhexidine plus mupirocin in ICU patients, a head-to-head trial of these strategies is needed. In the meantime, hospitals can choose for themselves what is best.

    Even though S. aureus (MRSA+MSSA) is the #1 US healthcare-associated pathogen, it may not be a problem for some hospitals. Hospital-specific data should be used to determine the approach followed.

    Mupirocin should be reserved for select patients clinically deemed at high risk for MRSA infection rather than all ICU patients.

    While there are options other than mupirocin to reduce MRSA nasal carriage, I am not aware of robust evidence that suggests one is less likely to engender resistance over another. This would be an important area for exploration.

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  2. AUTHOR COMMENT June 6, 2013 at 8:31 am ET  -   .

    I am very sorry to hear about your mom. I hope she recovers soon. We performed this trial because we deeply care about prevention including how it is actually practiced by front line healthcare workers. We and others are working every day to make that better and more effective –both the strategy and how it is carried out each day in every room for every patient. Patients like you and your mom remind us all about the importance of why we do what we do. I wish your mom the very best in recovering from her infection.

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  3. June 4, 2013 at 4:43 pm ET  -   Angela DeLuca

    Hi there,

    My mom is currently fighting MRSA, which was contracted at some point during her surgery from a fall she took back in March. Now, we all know that infection is possible whenever you have a surgery, but this time it’s MRSA. She has been on multiple antibiotics, and has had two debridements, but it is still there. I am at this point hoping for a miracle, but not expecting one since the real problem is that you are dealing with humans on the job (nurses, doctors, etc.), and with humans it is a “job.” It seems that most people involved were overworked, and just couldn’t/can’t take the time out to handle the needs of each and every patient as they should. Whether it was the care in the hospital or nursing/rehab home, they were both understaffed. Therefore, the patients suffer. What I mean by that is when the nurse or aide tended to my mom, I found that they didn’t/don’t take the time to take the proper precautions, i.e., to change their gloves each time they touch something in patient’s room, place the sterlized tools on a sterile surface before they are used, place all used gauze, tape, etc. in the garbage pail and not on the patient’s bed or tray. I have noticed these things happening in each facility my mom was in and this is because the nurse or aide is just doing their job and not taking the time to think about what they are doing. A nurse come into mom’s room to give her IV antibiotics. She took all of the tools out of their sterlized packaging and then placed them onto her bed or food tray. Now, the tray was not cleaned before she did this. She just did it. The same nurse also placed the bloody gauze she took off my mom’s draining wound as well as the bloody gauze she used to clean my mom’s wound onto her bed or food tray as she was cleaning her. So, what I am saying basically is it doesn’t matter what preventative measures you come up with. What does matter is how they are practiced by the healthcare individuals. They really have to take this seriously. I don’t know what mandatory training the nurses have to go through, but it needs to be redone for all. We can’t worry about what things cost when it is the patient who is paying for it in the end, and it is their life or death. I have found that everything is about the money and not about the patient. How about we put what is most important first – the patient.

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  4. May 31, 2013 at 9:26 am ET  -   MAXIM

    Hi everyone! My name is Max! 27 years, the city of Chernigov Ukraine!

    very nice to see how the U.S.A cares for its citizens! Thanks to you for helping ensure that all over the world. As well as I send our gratitude medical organization CDC. Which protects us from the global virus cataclysm. Thank you very much! Regards Max!

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  5. May 30, 2013 at 5:00 pm ET  -   Russ Olmsted

    Hi Dr. Huang, congratulations to you and your colleagues on publishing your well designed and well executed investigation. Would you agree that your findings showcase the importance of a more horizontal orientation to patient-centric hygiene, aka “source control,” especially for those adults in ICUs? Your findings also suggest back to the future in terms of transmission-based precautions; e.g. Standard Precautions + source control may be as effective as layering on transmission-based precautions ala “Body Substance Isolation” that emerged in 1984. Last, while it can be monitored somewhat I worry about selection for high-level resistance to mupirocin among strains of Staphylococci if use is adopted broadly. There’s a bit more experience outside the U.S. but these studies do give me pause; Pérez-Roth E, et al 2013, Desroches M, et al 2013, McDanel JS, et al. 2013. Any comments? Are you aware of any alternative topical antimicrobials that can be use intra-nasally that might have lower selective pressure but equivalent efficacy as mupirocin?

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