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Reference: N Engl J Med 2013 Jun 13;368(24):2255, (level 1 [likely reliable] evidence)
Infections from methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens have become a major risk factor for preventable illness and death in health care settings, and patients admitted to intensive care units (ICUs) are at elevated risk. A common strategy for preventing MRSA infections involves screening of all patients upon ICU admission and isolation of patients testing positive for colonization. However, the optimal strategy for preventing healthcare-associated infections remains unclear. A recent cluster-randomized trial in 43 hospitals involving 74,256 adult patients admitted to 74 ICUs compared infections rates for 3 different MRSA prevention protocols
Hospitals were randomized for 18 months to MRSA screening and isolation (control) vs. targeted decolonization vs. universal decolonization. In control hospitals, all patients were screened upon ICU admission, and contact precautions were put in place for all patients with any positive MRSA test, MRSA infection, or history of MRSA colonization. In hospitals with targeted decolonization, all ICU patients were screened and those testing positive had decolonization for 5 days with mupirocin 2% ointment intranasally twice daily and bathing with chlorhexidine 2%-impregnated cloths daily. In hospitals with universal decolonization, all ICU patients had decolonization without any MRSA screening. The targeted and universal decolonization groups had contact precautions similar to control group. Prior to the intervention period, baseline data were collected for all hospitals for 1 year.
The changes in outcome rates between the baseline and intervention periods were compared among the groups. The reduction in the overall rate of bloodstream infections from any pathogen was significantly greater with universal decolonization (-2.5 per 1,000 patient-days) than with either targeted decolonization (-1.1 per 1,000 patient-days) or control (-0.1 per 1,000 patient-days). The reduction was also significantly greater for targeted decolonization vs. control. However, there were no significant differences in the changes in MRSA-specific infection rates among the groups (-0.1 with universal decolonization vs. +0.1 with targeted decolonization vs. +0.1 with control per 1,000 patient days). Universal decolonization was associated with a significant reduction in MRSA-positive cultures (including both MRSA infection and colonization) compared to the control group (-1.3 vs. -0.2 per 1,000 patient-days, p = 0.003).
For more information, see the Methicillin-resistant Staphylococcus aureus (MRSA) infection topic in DynaMed.