Value of Whole‐Body Washing With Chlorhexidine for the Eradication of Methicillin‐Resistant Staphylococcus aureus: A Randomized, Placebo‐Controlled, Double‐Blind Clinical Trial •
Whole-body washing with antiseptic solution has been widely used as part of eradication treatment for colonization with methicillin-resistant Staphylococcus aureus (MRSA), but evidence for the effectiveness of this measure is limited.
To study the efficacy of whole-body washing with chlorhexidine for the control of MRSA.
Randomized, placebo-controlled, double-blinded clinical trial.
University Hospital of Heidelberg and surrounding nursing homes.
MRSA carriers who were not treated concurrently with antibiotics effective against MRSA were eligible for the study.
Five days of whole-body washing with either 4% chlorhexidine solution (treatment group) or with a placebo solution. All patients received mupirocin nasal ointment and chlorhexidine mouth rinse. The outcome was evaluated 3, 4, 5, 9, and 30 days after treatment with swab samples taken from several body sites.
Of 114 patients enrolled in the study (56 in the treatment group and 58 in the placebo group), 11 did not finish treatment (8 from the treatment group and 3 from the placebo group [P=.02]). At baseline, the groups did not differ with regard to age, sex, underlying condition, site of MRSA colonization, or history of MRSA eradication treatment. Eleven patients were MRSA-free 30 days after treatment (4 from the treatment group and 7 from the placebo group [P=.47]). Only groin-area colonization was significantly better eradicated by the use of chlorhexidine. The best predictor for total eradication was a low number of body sites positive for MRSA. Adverse effects were significantly more frequent in the treatment group than in the placebo group (any symptom, 71% vs 33%) but were reversible in most cases.
Whole-body washing can reduce skin colonization, but it appears necessary to extend eradication measures to the gastrointestinal tract, wounds, and/or other colonized body sites if complete eradication is the goal.
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- "In all, the levels of evidence of the above studies support the following conclusions: P.-Y. Levy et al. • there is established scientific evidence (grade A recommendation ) that mupirocin is more effective than other agents in eradicating nasal S. aureus carriage 23—34; • there is established scientific evidence (grade A recommendation ) that 2% alcoholic chlorhexidine is more effective than aqueous iodized povidone in preventing superficial and deep infection  ; • there is no established scientific evidence that mupirocin alone reduces the risk of orthopedic S. aureus SSI  : the cited studies report a sub-significant trend; • there is, on the other hand, established scientific evidence (grade A recommendation) for a significant reduction in S. aureus SSI with associated mupirocin and 2% chlorhexidine antiseptic solution in case of positive nasal screening, but this significant reduction fails to hold for the orthopedic surgery subgroup . "
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ABSTRACT: Staphylococcus aureus is the pathogen most frequently implicated in infection on orthopedic hardware; various strategies are deployed to limit the risk of transmission and surgical infection.
The present study is based on a meta-analysis assessing firstly the relationship between nasal carriage of S. aureus and the development of osteo-articular infection and secondly current methods of decolonization.
The meta-analysis showed increased risk of surgical site infection in case of nasal carriage of S. aureus: OR=5.92, 95% CI [1.15-30.39]; P=0.033. For cross-transmission, a scientifically proven reduction in surgical site S. aureus levels is ensured by associated mupirocin and 2% chlorhexidine antiseptic solution in subjects with positive nasal screening results for all surgical procedures taken together; the reduction was not, however, significant in the orthopedic surgery subgroup. The meta-analysis confirmed these findings: OR=0.60, 95% CI [0.34-1.06]; P=0.08.
The literature review confirmed that nasal carriage of S. aureus is a major risk factor for surgical site infection. The efficacy of eradication could not be demonstrated for orthopedic surgery as samples were too small. The positive trend found, however, should encourage further studies with sufficient power and risk/benefit should meanwhile be assessed on a case-by-case basis.
Level 2. Meta-analysis.
Available from: Anthony D Ormerod
- "In another study 23% of diabetic foot ulcers were infected . MRSA infections are also a frequent cause of abscesses  and novel or better bactericidal agents that can be applied to wounds for decolonisation or prevention are urgently needed . "
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Endogenous nitric oxide (NO) kills bacteria and other organisms as part of the innate immune response. When nitrite is exposed to low pH, NO is generated and has been used as an NO delivery system to treat skin infections. We demonstrated eradication of MRSA carriage from wounds using a topical formulation of citric acid (4.5%) and sodium nitrite (3%) creams co-applied for 5 days to 15 wounds in an observational prospective pilot study of 8 patients.
Following treatment with topical citric acid and sodium nitrite, 9 of 15 wounds (60%) and 3 of 8 patients (37%) were cleared of infection. MRSA isolates from these patients were all sensitive to acidified nitrite in vitro compared to methicillin-sensitive S. aureus and a reference strain of MRSA.
Nitric oxide and acidified nitrite offer a novel therapy for control of MRSA in wounds. Wounds that were not cleared of infection may have been re-contaminated or the bioavailability of acidified nitrite impaired by local factors in the tissue.
Available from: Iris F. Chaberny
- "The effects of a decolonisation treatment that have been reported to date are conflicting [13, 22–25]. We found a significant effect of one topical decolonisation therapy during the patient’s first MRSA-positive hospital stay even though we could not control the adherence to the decolonisation protocol (data not shown in detail). "
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ABSTRACT: A better knowledge of methicillin-resistant Staphylococcus aureus (MRSA) persistence in hospitalised patients may impact on specific prevention strategies. We have investigated the persistence of MRSA-carriage in patients admitted and re-admitted to a university hospital.
Between January 2002 and October 2005 all MRSA-positive patients admitted to the university hospital of Hannover Medical School were assessed at first admission and all subsequent re-admissions. Patients re-admitted at least once were analysed for the persistence or loss of MRSA. The association of possible factors influencing the persistence of MRSA colonisation or infection (age group, gender, decolonisation therapy during first hospital stay due to MRSA positivity and colonisation of different anatomical sites) was analysed using univariate, multivariate and time-dependent analyses.
A total of 1,032 patients who had tested positive at least once for MRSA were admitted to our hospital during the study period, accounting for 2,038 admissions. Of these patients, 403 (39.1%) were admitted more than once (from two times to 21 times), and 238 (59.1%) of the re-admitted patients remained MRSA positive during all subsequent admissions. Fifty-five (13.6%) patients tested MRSA negative at their last admission, and 61 (15.1%) tested MRSA negative at at least two consecutive admissions. In 27 (6.7%) patients, the MRSA status differed more than once between subsequent admissions. Overall, the half-life time (HLT) of MRSA persistence was 549 days, with the duration of persistence dependent on the colonisation of different anatomical sites (HLT only wounds 117 days; HLT mouth, throat, bronchial secretions 627 days; HLT nose, wounds and other body sites 801 days; p < 0.01) and was prolonged if more than one body site was MRSA-positive (HR 2.18, 95% confidence interval 1.52-3.15).
A detailed knowledge of the dynamics of the loss of MRSA infection could result in a reduction of the incidence of MRSA in the future. Multiple anatomical site carriage of MRSA appeared to predict a prolonged persistence in our cohort of patients re-admitted to a university hospital.
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