Findings Among the Research Featured at First IDWeek Conference
Cleansing the skin of all intensive care patients daily with antiseptic wipes and applying an antimicrobial ointment to the nose of all intensive-care patients significantly decreases their risk of having a clinical methicillin-resistant Staphylococcus aureus (MRSA) isolate and also decreases their risk of bloodstream infections due to all pathogens, according to a study of 75,000 patients. The study results are being presented for the first time at IDWeek in San Diego, 2012 and may suggest a major change in health care practice that could help save lives.
“The strategy that proved to be most effective was perhaps the most straightforward: All patients were bathed daily with chlorhexidine antiseptic soap for the duration of their ICU stay and all received mupirocin antibiotic ointment applied in the nose for five days,” said Dr. Mary Hayden, associate professor of infectious diseases and pathology at Rush University Medical Center, and one of the co-authors of the study. “This approach proved to be more effective than screening intensive care unit (ICU) patients for the bacteria and then focusing on those identified as carriers.”
Investigators found that the number of patients harboring MRSA, those at risk for later illness and for spreading it to others, dropped by more than a third. Bloodstream infections caused by MRSA and other pathogens decreased by almost half.
The study involved nearly 75,000 patients in 43 mostly community hospitals in 16 states and involved each hospital’s own quality improvement team, which indicate that the study’s findings may have widespread applicability to hospitals across the country.
The trial, which was conducted in 2010-2011, was a collaborative effort involving several academic institutions, the Hospital Corporation of America (HCA), and research programs at two U.S. Department of Health and Human Services’ agencies, the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC). The study concept and design was created by investigators in the CDC’s Prevention Epicenter Program at the University of California, Irvine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Rush University and Washington University in St. Louis. A total of 74 adult ICUs in the 43 HCA-affiliated hospitals took part. AHRQ’s Healthcare Associated Infections program provided funding to conduct the research as part of the agency’s Developing Evidence to Inform Decisions about Effectiveness program.
“In ICUs, these infections are generally 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,” said Dr. Robert Weinstein, a co-author of the study. He is professor of medicine at Rush and chair of the Department of Medicine of John H. Stroger, Jr. Hospital of Cook County.
“These are often preventable infections that can cause serious complications for patients. These results are critical when assessing whether other measures, either targeted or universal, would have greater impact,” Weinstein said.
The 43 participating hospitals were randomized and assigned one of three approaches. One group was to continue routine care, screen ICU patients for MRSA and isolate those found to be carrying the bacteria. The second group similarly screened and isolated carriers but also provided bathing with chlorhexidine soap and then nasal mupirocin ointment to help remove (decolonize) MRSA from the body. The third group of hospital ICUs eliminated all screening and instead treated every patient who was admitted with the daily chlorhexidine bath and five days of mupirocin ointment in the nose.
The number of ICU patients carrying MRSA fell by approximately 35 percent in the universal decolonization group, compared to no change among patients who were screened and isolated.
Bloodstream infection due to all causes in the universal decolonization intervention group decreased to 3.6 cases per 1,000 patient days in the hospital, down from the previous rate of 6.1.
Lead researcher Dr. Susan Huang, an associate professor at the University of California, Irvine School of Medicine and medical director of epidemiology and infection prevention at University of California, Irvine Healthcare, cautioned that the results apply only to ICUs and that widespread use of antiseptic soap and ointment in patient populations at low risk for infection might increase resistance to these products without providing benefit. In addition, there is concern whether broad adoption within critical-care settings could speed emerging antibiotic resistance. These issues will require further research, Huang said. Formal cost analyses also will be needed. CDC is in the process of evaluating how the findings should inform its infection prevention guidelines.
The study is among the significant work being discussed at the inaugural IDWeek meeting, taking place through Sunday in San Diego. IDWeek features the latest science and bench-to-bedside approaches in prevention, diagnosis, treatment, and epidemiology of infectious diseases, including HIV, across the lifespan. More than 1,500 abstracts from scientists in this country and internationally will be highlighted over the conference’s five days.