UCI-led study identifies best strategy for curbing MRSA in ICU patients
Simple antimicrobial treatment for all reduces bloodstream infections by 44 percent
A sweeping study on the issue of antibiotic-resistant bacteria in hospitals shows that using antimicrobial soap and ointment on all intensive-care patients significantly cuts bloodstream infections.
The data — being presented today at the IDWeek 2012 meeting in San Diego — suggests a major change in healthcare practice that could help save lives.
Led by UC Irvine infectious diseases specialist Dr. Susan Huang, the study involved nearly 75,000 patients in 43 community hospitals in 16 states and utilized the facilities’ regular staff rather than specially trained researchers. Accordingly, its findings about “universal decolonization” for methicillin-resistant Staphylococcus aureus, or MRSA, may have widespread applicability across the country.
Of the strategies tested, the one that proved most effective was, arguably, the simplest and most straightforward: Instead of screening ICU patients for the MRSA bacteria and then following protocol with those identified as carriers, ICU staff took just one proactive approach with all patients. They were bathed daily using chlorhexidine soap for the duration of their ICU stay, and each had mupirocin ointment applied inside his or her nasal passages for five days.
Investigators found that the number of patients harboring MRSA — not sick because of it but at risk of later illness and spreading it to others — dropped by more than a third. Bloodstream infections caused by MRSA and all other pathogens decreased by nearly half.
“This trial provides strong evidence that removing bacteria from the skin and nose is highly effective at preventing infection in high-risk intensive-care patients,” said Huang, associate professor of medicine and medical director of epidemiology and infection prevention with UC Irvine Healthcare.
“A 44 percent reduction in infection is very promising for improving medical care and protecting highly vulnerable patients,” she added. “It suggests that treating all ICU patients with this strategy is beneficial. If adopted, it may make screening for drug-resistant organisms unnecessary.”
The trial, which was conducted in 2010-11, was a collaborative effort involving several academic institutions, the Centers for Disease Control & Prevention and Hospital Corporation of America. Its concept and design came from investigators in the CDC’s Prevention Epicenter grant program at UC Irvine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Rush University and Washington University in St. Louis. A total of 74 adult ICUs in nearly four dozen HCA-affiliated hospitals took part. Major funding was provided by the federal Agency for Healthcare Research & Quality.
Dr. Scott Fridkin, vice chair of IDWeek and a CDC senior medical epidemiologist, said the partners planned the study to affect bedside clinical practice. “We know that easy-to-use solutions help clinicians protect patients from MRSA and other drug-resistant infections that are known to be deadly foes in all healthcare settings,” he said. “The ultimate goal of this effort is to prevent infections and save patients’ lives.”
Many infections in ICUs are caused by increasingly antibiotic-resistant bacteria that, for most people, live harmlessly on the skin or, particularly in the case of MRSA, in the nose. These often preventable infections can cause serious complications for patients, prolonging hospital stays, driving up costs and increasing the risk of death. More and more states have mandated MRSA screening by hospitals, but some experts question whether other measures, either targeted or universal, might have greater impact.
Huang and her colleagues looked at the potential benefit of treating all ICU patients. The 43 participating hospitals were randomized and assigned one of three approaches. One group screened ICU patients for MRSA and isolated those found to be carriers. The second group did the same but added the special bath and ointment for carriers. The third group eliminated all screening and instead dealt uniformly with every ICU patient admitted: daily bathing with chlorhexidine soap and five days of mupirocin ointment in the nose.
The proportion of ICU patients harboring MRSA fell by about 35 percent in the third group — under “universal decolonization” — compared with no drop among patients who were screened and isolated. Bloodstream infections due to all pathogens in this group decreased to 13.7 cases per 1,000 patients, down from a rate of 23.7 at the beginning of the study.
Huang cautioned that the results apply only to ICUs and that widespread use of antimicrobial soap and ointment in patient populations at low risk for infection might have little effect. In addition, there is concern about whether broad adoption of this approach — even just in critical-care settings — could speed emerging antibiotic resistance. These issues will require further research, Huang said. Formal cost analyses also will be needed. The CDC is in the process of evaluating how the findings should inform its infection prevention guidelines.
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