Eradication of MRSA from carriers by means of whole-body washing with an antiseptic in combination with Mupirocin nasal ointment

Clinical Evidence for the Use of Octenidine Dihydrochloride to Prevent Healthcare-Associated Infections and Decrease Staphylococcus aureus Carriage or Transmission-A Review

BACKGROUND

The antiseptic agent octenidine dihydrochloride (OCT) is used for skin preparation, for Staphylococcus aureus decolonization, and within bundles for the prevention of catheter-related or surgical site infections (SSIs). Here, we review the evidence for the effects of OCT from clinical studies.

METHODS

Review of studies published in the Medline, Scopus, and Cochrane databases until August 2022, performed in clinical settings and reporting on effects of OCT on S. aureus carriage/transmission, SSI prevention, and prevention of intensive care unit (ICU)-related or catheter-related bloodstream and insertion site infections.

RESULTS

We included 31 articles. The success of S. aureus decolonization with OCT-containing therapies ranged between 6 and 87%. Single studies demonstrated that OCT application led to a reduction in S. aureus infections, acquisition, and carriage. No study compared OCT for skin preparation before surgical interventions to other antiseptics. Weak evidence for the use of OCT for pre-operative washing was found in orthopedic and cardiac surgery, if combined with other topical measures. Mostly, studies did not demonstrate that daily OCT bathing reduced ICU-/catheter-related bloodstream infections with one exception.

CONCLUSIONS

There is a need to perform studies assessing the clinical use of OCT compared with other antiseptics with respect to its effectiveness to prevent nosocomial infections.

Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients

BACKGROUND

Groin hernia repair constitutes a very common procedure in general surgery. Minimal invasive closure of groin hernia has evolved to become the standard means of closure. However, there seems to be a gender-associated discrimination with regard to endoscopic groin hernia repair. We investigated the rate of endoscopic closure in female patients undergoing groin hernia closure.

MATERIALS AND METHODS

A retrospective analysis of the data of patients undergoing elective groin hernia repair within a four-year period from 2013 to 2016 was performed. The rate of endoscopic hernia repair was calculated for both genders.

RESULTS

Eight hundred and forty-six patients including 94 females and 752 males were included for analysis. The female group was significantly older compared to the male group (68.0 vs. 61.0 yrs, P=0.02). The rate of endoscopic groin hernia repair was significantly lower in the female group compared to in the male cohort (30% vs. 60%, P=0.001). The overall duration of surgery was 74.0min in the female cohort and 93.0min in the male group, P=0.001. However, there was no statistically significant difference amongst both groups with regard to the duration of surgery for endoscopic repair: 78.0min in the female group and 89.0min in the male group, P=0.67.

CONCLUSION

Findings from this retrospective collective suggests that, there might be some degree of sex discrimination with regard to endoscopic groin hernia repair in favor of the male population.

Risk of recurrence following mesh associated incisional hernia repair using the retromuscular technique in patients with relevant medical conditions

BACKGROUND

Incisional hernia is a common problem following open abdominal surgery. Hernia repair in patients with relevant medical conditions is a topic of controversy due to the high risk of morbidity and recurrence. We investigated the risk of recurrence in patients with relevant medical conditions managed with a prosthesis in the retromuscular position.

METHODS

A retrospective review of the data of patients undergoing midline incisional hernia repair was performed. The outcomes of patients with relevant concomitant medical conditions defined as ASA scores >2 were compared with those of healthier patients with ASA scores ≤2.

RESULTS

115 patients including 41 with ASA >2 and 74 with ASA ≤2 were included for analysis. There were no statistically significant differences amongst both groups with regard to the size of the hernia defect, the duration of surgery (123.0 ± 71 vs. 149.0 ± 92 min, p = 0.73), the incidence of postoperative seroma (14.6% vs. 29.7%, p = 0.07), postoperative hematoma (12.2% vs. 4.1%, p = 0.10) and surgical site infection (14.6% vs. 8.1%, p = 0.27). No statistically significant difference was seen amongst both groups with respect to the rate of long-term recurrence after a median follow-up of 63.0 ± 36 months (12.2% vs. 6.8%, p = 0.32).

CONCLUSION

Relevant medical condition alone cannot be seen as a contraindication for midline incisional hernia repair using the retromuscular technique. Rates of morbidity and long-term recurrence following mesh-associated closure are not difference from those of healthier patients.

Wash or wipe? A comparative study of skin physiological changes between water washing and wiping after skin cleaning

BACKGROUND/PURPOSE

Presently, skin-cleaning agents that claim to be removed by water or wiping alone are commercially available and have been used for the purpose of bed baths. However, there is a lack of knowledge on how water washing and wiping differently affect skin physiological functions or ceramide content. The aim of this study was to compare the effects of water washing and wiping on skin physiological functions and ceramide content.

METHODS

Three kinds of the cleaning agents with different removal techniques (ie, water washing and wiping) were used in this study. Skin physiological functions (ie, transepidermal water loss, skin hydration, and skin pH) and skin ceramide content were measured before and after seven consecutive days of the application of each cleaning agent.

RESULTS

No significant differences in skin physiological functions or ceramide content were observed between water washing and wiping.

CONCLUSION

Cleaning agents that claim to be removed by water washing or wiping do not affect skin physiological functions or ceramide content by either removal method.

Integrated MRSA-Management (IMM) with prolonged decolonization treatment after hospital discharge is effective: a single centre, non-randomised open-label trial

BACKGROUND

Guidelines for the control of hospital-acquired MRSA include decolonization measures to end MRSA carrier status in colonized and infected patients. Successful decolonization typically requires up to 22 days of treatment, which is longer than the average hospital length of stay (LOS). Incomplete decolonization is therefore common, with long-term MRSA carriage as a consequence. To overcome this, we developed an integrated MRSA Management (IMM) by extending MRSA decolonization to the outpatient and domestic setting. The protocol makes use of polyhexanide-based products, in view of reported qac-mediated resistance to chlorhexidine in S. aureus and MRSA.

METHODS

This is a prospective, single centre, controlled, non-randomized, open-label study to evaluate the efficiency of the IMM concept. The outcome of guideline-approved decolonization during hospital stay only (control group; n = 201) was compared to the outcome following IMM treatment whereby decolonization was continued after discharge in the domestic setting or in a long-term care facility (study group; n = 99). As a secondary outcome, the effect of MRSA-status of skin alterations was assessed.

RESULTS

The overall decolonization rate was 47 % in the IMM patient group compared to 12 % in the control group (p < 0.01). The continued treatment after hospital discharge was as effective as treatment completed during hospitalization, with microbiologically-confirmed decolonization (patients with completed regimes only) obtained with 55 % for the IMM group and 43 % for the control group (p > 0.05). For patients with skin alterations (e.g. wounds and entry sites), decolonization success was 50 % if the skin alterations were MRSA-negative at baseline, compared to 22 % success for patients entering the study with MRSA-positive skin alterations (p < 0.01).

CONCLUSIONS

The IMM strategy offers an MRSA decolonization protocol that is feasible in the domestic setting and is equally effective compared with inpatient decolonization treatment when hospital LOS is long enough to complete the treatment. Moreover, for patients with average LOS, decolonization rates obtained with IMM are significantly higher than for in-hospital treatment. IMM is a promising concept to improve decolonization rates of MRSA-carriers for patients who leave the hospital before decolonization is completed.

Value of Whole-Body Washing With Chlorhexidine for the Eradication of Methicillin-ResistantStaphylococcus aureus:A Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Background.

Whole-body washing with antiseptic solution has been widely used as part of eradication treatment for colonization with methicillin-resistantStaphylococcus aureus(MRSA), but evidence for the effectiveness of this measure is limited.

Objective.

To study the efficacy of whole-body washing with chlorhexidine for the control of MRSA.

Design.

Randomized, placebo-controlled, double-blinded clinical trial.

Setting.

University Hospital of Heidelberg and surrounding nursing homes.

Patients.

MRSA carriers who were not treated concurrently with antibiotics effective against MRSA were eligible for the study.

Intervention.

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.

Results.

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.

Conclusion.

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.

Trial Registration.

ClinicalTrials.gov identifier: NCT00266448.

Rising Methicillin-Resistant Staphylococcus aureus Infections in Ear, Nose, and Throat Diseases

The increasing incidence of methicillin-resistant Staphylococcus aureus infections (MRSA) in ENT diseases is becoming a big clinical concern. Here two patients are described who developed MRSA infections presented with unusual post-FESS epistaxis and postmastoidectomy perichondrial abscess and failed treatment with broad spectrum intravenous antibiotics. Following treatment with oral linezolid combined with local mupirocin dressing both patients fully recovered.

Infection control in United Kingdom neonatal units: variance in practice and the need for an evidence base

Infection prevention is a cornerstone of good neonatal care. There are, however, few research data to support infection control approaches in this population. Through a structured telephone interview we surveyed all neonatal units in the United Kingdom to identify infection control issues, practices and policies. Eighty seven percent of the 198 neonatal units participated. Twenty one units (12.2%) had closed with infection control issues in the last year; 14.1% had current infection control concerns; 81.5% of units decolonised MRSA positive infants, but over 15 regimens were used. Wide variations in hygiene measures were identified; 22.1% of units used theatre scrubs for all staff, 7.6% used aprons and 5.8% required gloves to be worn when entering clinical areas. Only 54% required hand washing and alcohol gel before entry to a patient care area; 11.6% required only the use of alcohol gel.

Although infection control issues are resulting in neonatal unit closures and risks to patients, there are considerable variations in hygiene and screening practices. There is little data to support the safety or efficacy of decolonisation in neonatal populations, but this is widely practised. Research needs to be carried out to evaluate the effectiveness of screening practices and decolonisation in order that a consistent evidence-based approach can be applied.

Antibiotic Treatment of Multidrug-Resistant Organisms in Cystic Fibrosis

Respiratory tract infection with eventual respiratory failure is the major cause of morbidity and mortality in cystic fibrosis (CF). Infective exacerbations need to be treated promptly and effectively to minimize potentially accelerated attrition of lung function. The choice of antibiotic depends on in vitro sensitivity patterns. However, physicians treating patients with CF are increasingly faced with infection with multidrug-resistant isolates of Pseudomonas aeruginosa. In addition, innately resistant organisms such as Burkholderia cepacia complex, Stenotrophomonas maltophilia and Achromobacter (Alcaligenes) xylosoxidans are becoming more prevalent. Infection with methicillin-resistant Staphylococcus aureus (MRSA) is also a problem. These changing patterns probably result from greater patient longevity and increased antibiotic use for acute exacerbations and maintenance care. Multidrug-resistant P. aeruginosa infection may be treated successfully by using two antibiotics with different mechanisms of action. In practice antibiotic choices have usually been made on a best-guess basis, but recent research suggests that more directed therapy can be achieved through the application of multiple-combination bactericidal testing (MCBT). Aerosol delivery of tobramycin for inhalation solution achieves high endobronchial concentrations that may overcome bacterial resistance as defined by standard laboratory protocols. Resistance to colistin is rare and this antibiotic should be seen as a valuable second-line drug to be reserved for multidrug-resistant P. aeruginosa. The efficacy of new antibiotic groups such as the macrolides needs to be evaluated.CF units should adopt strict segregation policies to interrupt person-to-person spread of B. cepacia complex. Treatment of panresistant strains is difficult and often arbitrary. Combination antibiotic therapy is recommended, usually tobramycin and high-dose meropenem and/or ceftazidime, but the choice of treatment regimen should always be guided by the clinical response.The clinical significance of S. maltophilia, A. xylosoxidans and MRSA infection in CF lung disease remains uncertain. If patients show clinical decline and are chronically colonized/infected with either of the former two pathogens, treatment is recommended but efficacy data are lacking. There are defined microbiological reasons for attempting eradication of MRSA but there are no proven deleterious effects of this infection on lung function in patients with CF. Various treatment protocols exist but none has been subject to a randomized, controlled trial. Multidrug-resistant microorganisms are an important and growing issue in the care of patients with CF. Each patient infected with such strains should be assessed individually and antibiotic treatment planned according to in vitro sensitivity, patient drug tolerance, and results of in vitro studies which may direct the physician to antibiotic combinations most likely to succeed.

Use of octenidine dihydrochloride in meticillin-resistant Staphylococcus aureus decolonisation regimens: a literature review

Decolonisation of patients colonised with meticillin-resistant Staphylococcus aureus (MRSA) is one of the recommended methods for controlling MRSA in hospitals but there is a limited choice of agents that can be used. Octenidine dihydrochloride is a relatively new antiseptic that has been used for MRSA decolonisation in some countries. On reviewing available literature on its use for MRSA decolonisation, only four observational studies were found. All of these were small studies, which differed in study design. MRSA decolonisation rates of 6-75% have been reported. Patients with wound colonisation were included in these studies but it was not clear if the hair was treated in two of these. Octenidine appears to be as effective as chlorhexidine for MRSA decolonisation with fewer adverse effects, but large randomised trials incorporating octenidine as a skin disinfectant for MRSA decolonisation need to be undertaken to confirm its usefulness in clinical settings.

Success of MRSA eradication in hospital routine: depends on compliance

BACKGROUND

To prevent transmission of MRSA, eradication by antiseptic washings and nasal ointment is recommended. There are few studies, which investigated the success of eradication of MRSA carriage during everyday clinical working conditions and results are controversial. We wanted to assess the effectiveness of MRSA eradication procedures--especially octenidine whole body washings and mupirocin nasal ointment--under conditions of everyday life.

PATIENTS AND METHODS

We retrospectively analyzed the files of all patients who were admitted to the medical department of a tertiary care hospital between 1999 and 2004 and who were infected or colonized by MRSA. According to hospital's standards of care patients should have been washed with octenidine and should have got mupirocin nasal ointment only in case of nasal carriage. Patients were regarded as MRSA-eradicated when swabs taken on three consecutive days, earliest, three days after discontinuation of antiseptic and antiinfective procedures were without proof of MRSA.

RESULTS

Only 6% of patients were eradicated. MRSA could be cultured from swabs taken on dismissal of 60% of patients. Fifteen percent of patients had only one or two negative series of swabs. In 19% of patients success of eradication remained unknown. Besides we found that under every day clinical working conditions compliance with several tasks of the eradication protocol was insufficient.

CONCLUSION

Under every day clinical working conditions MRSA eradication is successful only in few patients. Whole body washings should be tested in detailed studies before they should become a recommendation for eradication of MRSA.

Management of peritonitis in children receiving chronic peritoneal dialysis

Bacterial peritonitis is a major threat to long-term peritoneal membrane function in pediatric patients receiving chronic peritoneal dialysis (CPD). This review summarizes the demographics, risk factors, and current recommendations regarding diagnostic procedures, management, and prevention of peritonitis in children. Albeit decreasing in incidence, bacterial peritonitis remains a major cause of technique failure in children with endstage renal disease receiving CPD. The use of standardized diagnostic procedures, efficacious antibacterial treatment, and objective response criteria are crucial in improving the outcome of this complication. Current guidelines recommend combining a first- and third-generation cephalosporin for empiric therapy in uncomplicated cases. The initial use of a glycopeptide/third-generation cephalosporin combination should be restricted to patients with risk factors for severe disease, as defined by clinical presentation, young age (<2 years), and recent infection with a methicillin resistant micro-organism. Several risk factors for primary or relapsing peritonitis have been identified, some of which are amenable to preventive measures. These relate to catheter design and implantation technique, connection methodology, early catheter removal in refractory or relapsing peritonitis, and eradication of Staphylococcus aureus from the catheter exit site and/or nasal reservoirs in patients and their caregivers.

Antimicrobial drugs for treating methicillin-resistant Staphylococcus aureus colonization

BACKGROUND

Eradication strategies for methicillin-resistant Staphylococcus aureus (MRSA) are variable. We sought to summarize the evidence for use of antimicrobial agents to eradicate MRSA.

OBJECTIVES

To describe the effects of topical and systemic antimicrobial agents on nasal and extra-nasal MRSA carriage, adverse events, and incidence of subsequent MRSA infections.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group's trials register (August 2003), the Cochrane Central Register of Controlled Trials (Issue 3, 2003), MEDLINE (1966 to 2003), EMBASE (1988 to 2003), handsearched relevant literature, and contacted MRSA experts and the manufacturer of mupirocin.

SELECTION CRITERIA

Randomized controlled trials of patients colonized with MRSA comparing topical or systemic antimicrobials to placebo or no treatment, and trials comparing various combinations of topical or systemic agents to no treatment, placebo, or to topical or systemic agents.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied inclusion criteria to potentially relevant trials, assessed trial methodological quality, and extracted data. Primary outcomes included eradication of MRSA, infection due to MRSA, and adverse events.

MAIN RESULTS

Six trials (384 participants) met the inclusion criteria. No difference in MRSA eradication was detected in four studies: one that compared mupirocin to placebo, two that compared one systemic agent to no treatment (fusidic acid in one and rifampin or minocycline in the other) and one that compared mupirocin to topical fusidic acid and oral trimethoprim-sulfamethoxazole, examining nasal MRSA eradication as an outcome. One study compared minocycline to rifampin, with rifampicin being more effective in relation to eradication of MRSA from all sites at day 30 (relative risk 0.16; 95% confidence intervals 0.02 to 1.00), but the difference at 90 days was not statistically significant (n = 18). Two studies (one testing novobiocin and rifampin, the other ciprofloxacin and rifampin, versus trimethoprim-sulfamethoxazole and rifampin) did not demonstrate a difference in eradication of MRSA at all sites (n = 94). Adverse events with systemic agents occurred in up to 20% of participants, however reporting was sporadic and denominators small. All trials reported development of resistance to antimicrobial agents used.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to support use of topical or systemic antimicrobial therapy for eradicating nasal or extra-nasal MRSA. There is no demonstrated superiority of either topical or systemic therapy, or of combinations of these agents. Potentially serious adverse events and development of antimicrobial resistance can result from therapy.

MRSA patients: proven methods to treat colonization and infection

Methicillin-resistant Staphylococcus aureus (MRSA) infections continue to cause serious nosocomial infections in many hospitals. Measures used to control the spread of these infections include ongoing laboratory-based surveillance, placing colonized and infected patients in isolation, use of barrier precautions and handwashing and hand antisepsis. Culturing hospitalized patients at high risk of acquiring MRSA can facilitate detection and isolation of colonized patients. Eradicating MRSA nasal colonization among affected patients and healthcare personnel has also been as a control measure, with variable success. Eradicating MRSA nasal carriage from epidemiologically-implicated healthcare workers has been used on a number of occasions to control outbreaks. Attempts to eradicate MRSA colonization among affected patients has proven difficult. Of more than 40 different decolonization regimens that have been tested during the last 60 years, topical intranasal application of mupirocin ointment has proven to be the most effective. However, intranasal application of mupirocin has limited effectiveness in eradicating colonization in patients who carry the organism at multiple body sites. Furthermore, because decolonization of patients has virtually always been used in combination with other control measures, its efficacy has been difficult to determine. Because MRSA is transmitted primarily on the hands of healthcare workers, greater emphasis should be given to improving hand hygiene practices among health personnel. For patients infected with MRSA, vancomycin remains a drug of choice.