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Heal CF, Banks JL, Lepper PD, Kontopantelis E, van Driel ML. Topical antibiotics for preventing surgical site infection in wounds healing by primary intention. Cochrane Database Syst Rev 2016; 11:CD011426. [PMID: 27819748 PMCID: PMC6465080 DOI: 10.1002/14651858.cd011426.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Surgical site infections (SSI) can delay wound healing, impair cosmetic outcome and increase healthcare costs. Topical antibiotics are sometimes used to reduce microbial contaminant exposure following surgical procedures, with the aim of reducing SSIs. OBJECTIVES The primary objective of this review was to determine whether the application of topical antibiotics to surgical wounds that are healing by primary intention reduces the incidence of SSI and whether it increases the incidence of adverse outcomes (allergic contact dermatitis, infections with patterns of antibiotic resistance and anaphylaxis). SEARCH METHODS In May 2015 we searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL. We also searched clinical trial registries for ongoing studies, and bibliographies of relevant publications to identify further eligible trials. There was no restriction of language, date of study or setting. The search was repeated in May 2016 to ensure currency of included studies. SELECTION CRITERIA All randomized controlled trials (RCTs) and quasi-randomised trials that assessed the effects of topical antibiotics (any formulation, including impregnated dressings) in people with surgical wounds healing by primary intention were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and independently extracted data. Two authors then assessed the studies for risk of bias. Risk ratios were calculated for dichotomous variables, and when a sufficient number of comparable trials were available, trials were pooled in a meta-analysis. MAIN RESULTS A total of 10 RCTs and four quasi-randomised trials with 6466 participants met the inclusion criteria. Six studies involved minor procedures conducted in an outpatient or emergency department setting; eight studies involved major surgery conducted in theatre. Nine different topical antibiotics were included. We included two three-arm trials, two four-arm trials and 10 two-arm trials. The control groups comprised; an alternative topical antibiotic (two studies), topical antiseptic (six studies) and no topical antibiotic (10 studies), which comprised inert ointment (five studies) no treatment (four studies) and one study with one arm of each.The risk of bias of the 14 studies varied. Seven studies were at high risk of bias, five at unclear risk of bias and two at low risk of bias. Most risk of bias concerned risk of selection bias.Twelve of the studies (6259 participants) reported infection rates, although we could not extract the data for this outcome from one study. Four studies (3334 participants) measured allergic contact dermatitis as an outcome. Four studies measured positive wound swabs for patterns of antimicrobial resistance, for which there were no outcomes reported. No episodes of anaphylaxis were reported. Topical antibiotic versus no topical antibioticWe pooled the results of eight trials (5427 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with no topical antibiotic (RR 0.61, 95% CI 0.42 to 0.87; moderate-quality evidence downgraded once for risk of bias). This equates to 20 fewer SSIs per 1000 patients treated with topical antibiotics (95% CI 7 to 29) and a number needed to treat for one additional beneficial outcome (NNTB) (i.e. prevention of one SSI) of 50.We pooled the results of three trials (3012 participants) for the outcome of allergic contact dermatitis, however this comparison was underpowered, and it is unclear whether topical antibiotics affect the risk of allergic contact dermatitis (RR 3.94, 95% CI 0.46 to 34.00; very low-quality evidence, downgraded twice for risk of bias, once for imprecision). Topical antibiotic versus antiseptic We pooled the results of five trials (1299 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with using topical antiseptics (RR 0.49, 95% CI 0.30 to 0.80; moderate-quality evidence downgraded once for risk of bias). This equates to 43 fewer SSIs per 1000 patients treated with topical antibiotics instead of antiseptics (95% CI 17 to 59) and an NNTB of 24.We pooled the results of two trials (541 participants) for the outcome of allergic contact dermatitis; there was no clear difference in the risk of dermatitis between topical antibiotics and antiseptics, however this comparison was underpowered and a difference cannot be ruled out (RR 0.97, 95% CI 0.52 to 1.82; very low-quality evidence, downgraded twice for risk of bias and once for imprecision). Topical antibiotic versus topical antibioticOne study (99 participants) compared mupirocin ointment with a combination ointment of neomycin/polymyxin B/bacitracin zinc for the outcome of SSI. There was no clear difference in the risk of SSI, however this comparison was underpowered (very low-quality evidence downgraded twice for risk of bias, once for imprecision).A four-arm trial involved two antibiotic arms (neomycin sulfate/bacitracin zinc/polymyxin B sulphate combination ointment versus bacitracin zinc, 219 participants). There was no clear difference in risk of SSI between the combination ointment and the bacitracin zinc ointment. The quality of evidence for this outcome was low, downgraded once for risk of bias, and once for imprecision. AUTHORS' CONCLUSIONS Topical antibiotics applied to surgical wounds healing by primary intention probably reduce the risk of SSI relative to no antibiotic, and relative to topical antiseptics (moderate quality evidence). We are unable to draw conclusions regarding the effects of topical antibiotics on adverse outcomes such as allergic contact dermatitis due to lack of statistical power (small sample sizes). We are also unable to draw conclusions regarding the impact of increasing topical antibiotic use on antibiotic resistance. The relative effects of different topical antibiotics are unclear.
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Affiliation(s)
- Clare F Heal
- James Cook UniversityGeneral Practice and Rural MedicineMackay Base HospitalBridge RoadMackayQueenslandAustralia4740
- Anton Breinl Research Centre for Health Systems StrengtheningTownsvilleQueenslandAustralia
| | - Jennifer L Banks
- James Cook UniversitySchool of Medicine and DentistryMackayQueenslandAustralia4740
| | - Phoebe D Lepper
- James Cook UniversitySchool of Medicine and DentistryMackayQueenslandAustralia4740
| | - Evangelos Kontopantelis
- The University of ManchesterCentre for Health Informatics, Institute of Population HealthWilliamson Building, 5th FloorOxford RoadManchesterGreater ManchesterUKM13 9PL
| | - Mieke L van Driel
- The University of QueenslandDiscipline of General Practice, School of MedicineBrisbaneQueenslandAustralia4029
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West SK, Plantenga MS, Strausbaugh LJ. Use of Decolonization to Prevent Staphylococcal Infections in Various Healthcare Settings: Results of an Emerging Infections Network Survey. Infect Control Hosp Epidemiol 2015; 28:1111-3. [DOI: 10.1086/519930] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Accepted: 04/19/2007] [Indexed: 11/03/2022]
Abstract
Less than 20% of infectious diseases consultants work in hospitals that routinely employ decolonization therapy for individuals with staphylococcal carriage undergoing elective surgical procedures or for infection control efforts to limit nosocomial transmission of methicillin-resistantStaphylococcus aureus(MRSA). However, infectious diseases consultants frequently encounter patients with recurrent MRSA furunculosis and attempt to decolonize them.
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3
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Development of Mupirocin Resistance Among Methicillin-ResistantStaphylococcus aureusAfter Widespread Use of Nasal Mupirocin Ointment. Infect Control Hosp Epidemiol 2015. [DOI: 10.1017/s019594170000357x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractAll methicillin-resistantStaphylococcus aureus(MRSA) strains isolated from colonized or infected patients in a 625-bed public teaching hospital during an epidemic, and for 3 years thereafter, underwent susceptibility testing to mupirocin. Mupirocin resistance among MRSA increased markedly over this period (1990, 2.7%; 1991, 8.0%; 1992, 61.5%; 1993, 65%) in association with increased use of mupirocin ointment as an adjunct to infection control measures.
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4
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Emergence of High-Level Mupirocin Resistance in Methicillin-ResistantStaphylococcus aureusIsolated From Brazilian University Hospitals. Infect Control Hosp Epidemiol 2015. [DOI: 10.1017/s0195941700003581] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractSurveillance for methicillin-resistantStaphylococcus aureus(MRSA) was implemented in Rio de Janeiro and Uberlândia University Hospitals, which had different policies on use of mupirocin. One hundred fourteen multiresistant MRSA strains were isolated from 62 patients. Mupirocin resistance was observed in 63% of strains in Rio de Janeiro, where there was extensive use of topical mupirocin, and 6.1% in Uberlândia, where its use was rare.
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5
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Preventing Staphylococcal Infections by Eradicating Nasal Carriage of Staphylococcus aureus: Proceeding With Caution. Infect Control Hosp Epidemiol 2015. [DOI: 10.1017/s0195941700003441] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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6
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Evaluation of
mupA
Evigene in Comparison to Disk Diffusion for Detection of High-Level Mupirocin Resistance in Clinical Isolates of
Staphylococcus aureus. J Clin Microbiol 2010; 48:2953-4. [DOI: 10.1128/jcm.02237-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
ABSTRACT
High-level mupirocin resistance (H-Mu
r
) in
S. aureus
is associated with the
mupA
gene. The
mupA
Evigene test rapidly identifies this gene. This study assessed the performance of
mupA
Evigene compared to that of susceptibility disk testing.
mupA
Evigene detected H-Mu
r
in 6/179
S. aureus
isolates, and the results were concordant with those of susceptibility disk testing.
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Hu Y, Shamaei-Tousi A, Liu Y, Coates A. A new approach for the discovery of antibiotics by targeting non-multiplying bacteria: a novel topical antibiotic for staphylococcal infections. PLoS One 2010; 5:e11818. [PMID: 20676403 PMCID: PMC2910736 DOI: 10.1371/journal.pone.0011818] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 06/30/2010] [Indexed: 11/18/2022] Open
Abstract
In a clinical infection, multiplying and non-multiplying bacteria co-exist. Antibiotics kill multiplying bacteria, but they are very inefficient at killing non-multipliers which leads to slow or partial death of the total target population of microbes in an infected tissue. This prolongs the duration of therapy, increases the emergence of resistance and so contributes to the short life span of antibiotics after they reach the market. Targeting non-multiplying bacteria from the onset of an antibiotic development program is a new concept. This paper describes the proof of principle for this concept, which has resulted in the development of the first antibiotic using this approach. The antibiotic, called HT61, is a small quinolone-derived compound with a molecular mass of about 400 Daltons, and is active against non-multiplying bacteria, including methicillin sensitive and resistant, as well as Panton-Valentine leukocidin-carrying Staphylococcus aureus. It also kills mupirocin resistant MRSA. The mechanism of action of the drug is depolarisation of the cell membrane and destruction of the cell wall. The speed of kill is within two hours. In comparison to the conventional antibiotics, HT61 kills non-multiplying cells more effectively, 6 logs versus less than one log for major marketed antibiotics. HT61 kills methicillin sensitive and resistant S. aureus in the murine skin bacterial colonization and infection models. No resistant phenotype was produced during 50 serial cultures over a one year period. The antibiotic caused no adverse affects after application to the skin of minipigs. Targeting non-multiplying bacteria using this method should be able to yield many new classes of antibiotic. These antibiotics may be able to reduce the rate of emergence of resistance, shorten the duration of therapy, and reduce relapse rates.
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Affiliation(s)
- Yanmin Hu
- Medical Microbiology, Centre for Infection, Division of Cellular and Molecular Medicine, St George's, University of London, London, United Kingdom
- Helperby Therapeutics Group plc, London, United Kingdom
| | | | - Yingjun Liu
- Helperby Therapeutics Group plc, London, United Kingdom
| | - Anthony Coates
- Medical Microbiology, Centre for Infection, Division of Cellular and Molecular Medicine, St George's, University of London, London, United Kingdom
- Helperby Therapeutics Group plc, London, United Kingdom
- * E-mail:
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Abstract
Impetigo contagiosa is a common, superficial, bacterial infection of the skin characterised by an inflamed and infected epidermis caused by Staphylococcus aureus, Streptococcus pyogenes or both. The less common bullous impetigo is characterised by fragile fluid-filled vesicles and flaccid blisters, and is invariably caused by pathogenic strains of S. aureus. In bullous impetigo, exfoliative toxins are produced, although these are restricted to the area of infection and bacteria can be cultured from the blister contents. In the rare variant, staphylococcal scalded skin syndrome, the exfoliative toxins are spread haematogenously from a localised source causing widespread epidermal damage at distant sites.
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Affiliation(s)
- Michael J Sladden
- Department of Dermatology, Leicester Royal Infirmary, Leicester, LE1 5WW, UK
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Pérez-Roth E, López-Aguilar C, Alcoba-Florez J, Méndez-Alvarez S. High-level mupirocin resistance within methicillin-resistant Staphylococcus aureus pandemic lineages. Antimicrob Agents Chemother 2006; 50:3207-11. [PMID: 16940133 PMCID: PMC1563509 DOI: 10.1128/aac.00059-06] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The methicillin-resistant Staphylococcus aureus (MRSA) population in the Hospital Universitario Nuestra Señora de Candelaria over a 5-year period (1998 to 2002) was marked by shifts in the circulation of pandemic clones. Here, we investigated the emergence of high-level mupirocin resistance (Hi-Mup(r)). In addition to clonal spread, transfer of ileS2-carrying plasmids played a significant role in the dissemination of Hi-Mup(r) among pandemic MRSA lineages.
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Affiliation(s)
- Eduardo Pérez-Roth
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
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Johnston GA. Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants. Expert Rev Anti Infect Ther 2004; 2:439-46. [PMID: 15482208 DOI: 10.1586/14787210.2.3.439] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Impetigo is a common, superficial, bacterial infection of the skin characterized by an inflamed and infected epidermis. The rarer variant, bullous impetigo, is characterized by fragile fluid-filled vesicles and flaccid blisters and is invariably caused by pathogenic strains of Staphylococcus aureus. Bullous impetigo is at the mild end of a spectrum of blistering skin diseases caused by a staphylococcal exfoliative toxin that, at the other extreme, is represented by widespread painful blistering and superficial denudation (the staphylococcal scalded skin syndrome). In bullous impetigo, the exfoliative toxins are restricted to the area of infection, and bacteria can be cultured from the blister contents. In staphylococcal scalded skin syndrome the exfoliative toxins are spread hematogenously from a localized source causing widespread epidermal damage at distant sites. Both occur more commonly in children under 5 years of age and particularly in neonates. It is important to swab the skin for bacteriological confirmation and antibiotic sensitivities and, in the case of staphylococcal scalded skin syndrome, to identify the primary focus of infection. Topical therapy should constitute either fusidic acid (Fucidin, Leo Pharma Ltd) as a first-line treatment, or mupirocin (Bactroban, GlaxoSmithKline) in proven cases of bacterial resistance. First-line systemic therapy is oral or intravenous flucloxacillin (Floxapen, GlaxoSmithKline). Nasal swabs from the patient and immediate relatives should be performed to identify asymptomatic nasal carriers of Staphylococcus aureus. In the case of outbreaks on wards and in nurseries, healthcare professionals should also be swabbed.
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Affiliation(s)
- Graham A Johnston
- Department of Dermatology, Leicester Royal Infirmary, LE1 5WW Leicester, UK.
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Walker ES, Vasquez JE, Dula R, Bullock H, Sarubbi FA. Mupirocin-resistant, methicillin-resistant Staphylococcus aureus: does mupirocin remain effective? Infect Control Hosp Epidemiol 2003; 24:342-6. [PMID: 12785407 DOI: 10.1086/502218] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the efficacy of mupirocin ointment in reducing nasal colonization with mupirocin-susceptible, methicillin-resistant Staphylococcus aureus (MS MRSA) as well as mupirocin-resistant MRSA (MR MRSA). DESIGN Prospective evaluation in which patients colonized with MRSA were treated twice daily with 2% topical mupirocin ointment for 5 days. SETTING James H. Quillen Veterans' Affairs Medical Center. PATIENTS Forty hospitalized patients with two anterior nares cultures positive for MRSA within a 7-day period. METHODS Treated patients had post-treatment cultures at day 3 and weeks 1, 2, and 4. Isolates underwent mupirocin-susceptibility testing and DNA typing. MRSA clearance and type turnover were assessed for isolates that were mupirocin-susceptible, low-level (LL) MR MRSA and high-level (HL) MR MRSA. RESULTS Post-treatment nares cultures on day 3 were negative for 78.5%, 80%, and 27.7% of patients with MS MRSA, LL-MR MRSA, and HLMR MRSA, respectively. Sustained culture negativity at 1 to 4 weeks was more common in the MS MRSA group (91%) than in the LL-MR MRSA group (25%) or the HL-MR MRSA group (25%). Positive post-treatment cultures usually showed the same DNA pattern relative to baseline. Plasmid curing of 18 HL-MR MRSA resulted in 15 MS MRSA and 3 LL-MR MRSA. CONCLUSIONS Mupirocin was effective in eradicating MS MRSA, but strains of MR MRSA often persisted after treatment. This appeared to reflect treatment failure rather than exogenous recolonization. MR MRSA is now more prevalent and it is appropriate to sample MRSA populations for mupirocin susceptibility prior to incorporating mupirocin into infection control programs.
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Affiliation(s)
- Elaine S Walker
- James H Quillen Veterans' Affairs Hospital, James H. Quillen College of Medicine, East Tennessee State University, Johnson City 37614, USA
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12
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Jones PG, Sura T, Harris M, Strother A. Mupirocin resistance in clinical isolates of Staphylococcus aureus. Infect Control Hosp Epidemiol 2003; 24:300-1. [PMID: 12725362 DOI: 10.1086/502204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
One hundred isolates of Staphylococcs aureus were collected in a laboratory serving several hospitals and clinics in southeastern Wisconsin and tested for mupirocin susceptibility. Only two isolates of S. aureus showed mupirocin resistance. The mupirocin-resistant isolates were from hospitalized patients with positive blood cultures.
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Affiliation(s)
- Paula G Jones
- Department of Medicine, University of Wisconsin-Milwaukee Clinical Campus, Aurora Consolidated Laboratories, Aurora Sinai Medical Center, 53201-0342, USA
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13
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Pérez-Fontán M, Rosales M, Rodríguez-Carmona A, Falcón TG, Valdés F. Mupirocin resistance after long-term use for Staphylococcus aureus colonization in patients undergoing chronic peritoneal dialysis. Am J Kidney Dis 2002; 39:337-41. [PMID: 11840374 DOI: 10.1053/ajkd.2002.30553] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Mupirocin (Mup) has been used extensively to prevent Staphylococcus aureus (SAu) infections in patients undergoing peritoneal dialysis (PD). Resistance to Mup has been reported, but its relevance after long-term use of this drug in PD is unknown. Colonization by SAu was treated with topic Mup in our unit between September 1990 and December 2000. Sensitivity to Mup was tested in 437 strains of SAu isolated from 155 PD patients and 62 dialysis partners. Resistance to Mup was classified as low (minimal inhibitory concentration [MIC] > or = 8 microg/mL) or high (MIC > or = 512 microg/mL) degree. MIC90 was 0.125 microg/mL in 1990 to 1996 (5% low, 0% high-degree resistance), 64 microg/mL in 1997 to 1998 (6.6% low, 8.3% high-degree resistance), and 1,024 microg/mL in 1999 to 2000 (2.3% low, 12.4% high-degree resistance). Mup-resistant SAu were isolated from 25 patients and 13 partners a median of 15 months after starting PD. Resistance was associated frequently with repeated treatments of SAu recolonization, but was detected in 3 cases at the start of PD therapy. The accumulated incidence of SAu exit-site infection in the period 1997 to 2000 was 32.3% in patients colonized by Mup-resistant SAu as compared with 14.5% in those colonized by Mup-sensitive SAu (P = 0.03). Mup-resistant SAu have emerged in a significant proportion of our PD patients and dialysis partners. This emergence has resulted in a moderate, but significant, increase in the risk of SAu exit-site infection and raises concerns about the future of Mup as the therapy of choice for SAu colonization in patients undergoing chronic PD.
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Semret M, Miller MA. Topical mupirocin for eradication of MRSA colonization with mupirocin-resistant strains. Infect Control Hosp Epidemiol 2001; 22:578-80. [PMID: 11732789 DOI: 10.1086/501956] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Topical mupirocin was able to interrupt colonization of 52% and 68% of methicillin-resistant Staphylococcus aureus (MRSA)-colonized patients carrying mupirocin-resistant and -sensitive strains, respectively, including 44.4% and 85.7% of those colonized only in the nares. Although a trend to decreased effectiveness was seen for clearing mupirocin-resistant MRSA, this agent can decolonize many patients with resistant strains.
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Affiliation(s)
- M Semret
- Department of Microbiology, SMBD-Jewish General Hospital, Montreal, Quebec, Canada
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Harbarth S, Liassine N, Dharan S, Herrault P, Auckenthaler R, Pittet D. Risk factors for persistent carriage of methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2000; 31:1380-5. [PMID: 11096006 DOI: 10.1086/317484] [Citation(s) in RCA: 151] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2000] [Revised: 05/08/2000] [Indexed: 11/03/2022] Open
Abstract
We determined risk factors associated with persistent carriage of methicillin-resistant Staphylococcus aureus (MRSA) among 102 patients enrolled in a double-blind, placebo-controlled trial of nasally administered mupirocin ointment. MRSA decolonization was unsuccessful in 77 (79%) of 98 patients who met the criteria for evaluation. By univariate analysis, 4 variables were found to be associated with persistent MRSA colonization (P < .1 for all 4): absence of mupirocin treatment, previous fluoroquinolone therapy, > or = 2 MRSA-positive body sites, and low-level mupirocin resistance. After multivariable Cox proportional hazards modeling, the presence of > or = 2 positive body sites (adjusted hazard ratio [AHR], 1.7; 95% confidence interval [CI], 1.0-2.9) and previous receipt of a fluoroquinolone (AHR, 1.8; 95% CI, 1.0-3.3) were independently associated with MRSA persistence, whereas nasal mupirocin tended to confer protection (AHR, 0.6; 95% CI, 0.4-1.0). Low-level mupirocin resistance was observed in 9 genotypically different MRSA strains and was not independently associated with chronic MRSA carriage (AHR, 1.5; 95% CI, 0.9-2.5). Our findings suggest that multisite MRSA carriage and previous receipt of a fluoroquinolone are independent risk factors for persistent MRSA colonization.
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Affiliation(s)
- S Harbarth
- Infection Control Program, University Hospitals of Geneva, Geneva, Switzerland
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Hitomi S, Kubota M, Mori N, Baba S, Yano H, Okuzumi K, Kimura S. Control of a methicillin-resistant Staphylococcus aureus outbreak in a neonatal intensive care unit by unselective use of nasal mupirocin ointment. J Hosp Infect 2000; 46:123-9. [PMID: 11049705 DOI: 10.1053/jhin.2000.0786] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In September 1996, an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) colonization occurred in the neonatal intensive care unit (NICU) of our hospital. After failing to control the outbreak by conventional methods we implemented an intranasal blanket use programme of mupirocin ointment from the beginning of November 1997. In the programme, patients who had been carrying MRSA received intranasal administration of the ointment three times daily for the first three days and consecutively three times weekly, while newly admitted patients and those who had not been colonized were prophylactically medicated three times weekly. This blanket administration was executed for one month. Methicillin-resistant Staphylococcus aureus colonization became undetectable in all but one intubated inpatient who had already been colonized before the start of the programme, and no new acquisitions occurred until the middle of January 1998, seven weeks after the termination of the blanket use programme. The rate of colonized patients in the unit also decreased. During and after the programme, neither an increase in minimum inhibitory concentration for the antibiotic nor apparent adverse reactions in any of the treated patients were observed. We concluded that this procedure is an effective method of controlling an MRSA outbreak in an NICU when the outbreak cannot be managed with conventional measures.
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Affiliation(s)
- S Hitomi
- Department of Infection Control and Prevention, University of Tokyo Hospital, Tokyo, Japan
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Vasquez JE, Walker ES, Franzus BW, Overbay BK, Reagan DR, Sarubbi FA. The epidemiology of mupirocin resistance among methicillin-resistant Staphylococcus aureus at a Veterans' Affairs hospital. Infect Control Hosp Epidemiol 2000; 21:459-64. [PMID: 10926396 DOI: 10.1086/501788] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the clinical and molecular epidemiology of mupirocin-resistant (MR) and mupirocin-susceptible (MS) methicillin-resistant Staphylococcus aureus (MRSA) at a Veterans' Affairs hospital and to assess risk factors associated with the acquisition of MR MRSA. DESIGN All clinical MRSA isolates for the period October 1990 through March 1995 underwent susceptibility testing to mupirocin. Mupirocin resistance trends were measured, and MS MRSA and MR MRSA isolates underwent typing by pulsed-field gel electrophoresis (PFGE). A retrospective case-control study was conducted to evaluate risk factors for having MR versus MS MRSA. SETTING The James H. Quillen Veterans' Affairs Medical Center in Mountain Home, Tennessee, included a 324-bed acute-care hospital, a 120-bed nursing home, and a 525-bed domiciliary. Colonizations and infections with MRSA were endemic, and mupirocin ointment was commonly used. PATIENTS Inpatients and outpatients at the facility. RESULTS MS MRSA was recovered from 506 patients and MR MRSA from 126. Among MR MRSA isolates, 58% showed low-level mupirocin resistance (minimum inhibitory concentration [MIC] > or = 4 to 256 microg/mL), and 42% showed high-level mupirocin resistance (MIC > or = 512 microg/mL). A significant increase (P=.002) in the number of high-level MR isolates occurred during the 1993 to 1995 period. A case-control study showed that presence of a decubitus ulcer correlated with high-level resistant isolates (P<.05). The distribution of PFGE patterns did not differ for MR and MS MRSA CONCLUSIONS: Use of mupirocin ointment in a program aimed at managing endemic MRSA infection or colonization resulted in a significant increase in the recovery of high-level MR MRSA isolates. These isolates appeared to emerge from our existing MRSA pool. A case-control study provided few clues concerning patients likely to harbor MR MRSA. We confirmed the position that the extended use of mupirocin ointment should be avoided in settings where MRSA is endemic.
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Affiliation(s)
- J E Vasquez
- James H. Quillen Veterans' Affairs Medical Center and East Tennessee State University College of Medicine, Johnson City, 37614, USA
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Harbarth S, Dharan S, Liassine N, Herrault P, Auckenthaler R, Pittet D. Randomized, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother 1999; 43:1412-6. [PMID: 10348762 PMCID: PMC89288 DOI: 10.1128/aac.43.6.1412] [Citation(s) in RCA: 208] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Mupirocin has been widely used for the clearance of nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage during outbreaks, but no placebo-controlled trial has evaluated its value for eradicating MRSA carriage at multiple body sites in settings where MRSA is not epidemic. In a 1,500-bed teaching hospital with endemic MRSA, 102 patients colonized with MRSA were randomized into a double-blind, placebo-controlled trial and treated with either mupirocin (group M) or placebo (group P) applied to the anterior nares for 5 days; both groups used chlorhexidine soap for body washing. Follow-up screening, susceptibility testing, and genotyping were performed to evaluate treatment success, mupirocin or chlorhexidine resistance, and exogenous recolonization. At baseline, MRSA carriage was 60% in the nares, 38% in the groin, and 62% in other sites (skin lesions, urine). The MRSA eradication rate (all body sites) was 25% in group M (12 of 48 patients), compared to 18% in group P (9 of 50 patients; relative risk [RR], 0.72; 95% confidence interval [CI95], 0.33 to 1.55). At the end of follow-up, 44% of patients (19 of 43) were free of nasal MRSA in group M, compared to 23% (11 of 44) in group P (RR, 0.57; CI95, 0.31 to 1.04). Ten patients developed MRSA infections (three in group M and seven in group P). One mupirocin treatment failure was due to exogenous MRSA recolonization. No MRSA isolate showed chlorhexidine resistance or high-level mupirocin resistance; however, we observed an association (P = 0.003) between low-level mupirocin resistance at study entry (prevalence, 23%) and subsequent treatment failure in both study arms. These results suggest that nasal mupirocin is only marginally effective in the eradication of multisite MRSA carriage in a setting where MRSA is endemic.
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Affiliation(s)
- S Harbarth
- Infection Control Program, University Hospitals of Geneva, CH-1211 Geneva 14, Switzerland
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Ramsey MA, Bradley SF, Kauffman CA, Morton TM, Patterson JE, Reagan DR. Characterization of mupirocin-resistant Staphylococcus aureus from different geographic areas. Antimicrob Agents Chemother 1998; 42:1305. [PMID: 9593176 PMCID: PMC105817 DOI: 10.1128/aac.42.5.1305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Boyce JM. Preventing Staphylococcal Infections by Eradicating Nasal Carriage of Staphylococcus aureus: Proceeding with Caution. Infect Control Hosp Epidemiol 1996. [DOI: 10.2307/30141169] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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dos Santos KRN, de Souza Fonseca L, Filho PPG. Emergence of High-Level Mupirocin Resistance in Methicillin-Resistant Staphylococcus aureus Isolated from Brazilian University Hospitals. Infect Control Hosp Epidemiol 1996. [DOI: 10.2307/30141177] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Miller MA, Dascal A, Portnoy J, Mendelson J. Development of Mupirocin Resistance among Methicillin-Resistant Staphylococcus aureus after Widespread Use of Nasal Mupirocin Ointment. Infect Control Hosp Epidemiol 1996. [DOI: 10.2307/30141176] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Chapnick EK, Gradon JD, Kreiswirth B, Lutwick LI, Schaffer BC, Schiano TD, Levi MH. Comparative Killing Kinetics of Methicillin-Resistant Staphylococcus aureus by Bacitracin or Mupirocin. Infect Control Hosp Epidemiol 1996. [DOI: 10.2307/30142381] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Comparative Killing Kinetics of Methicillin-Resistant Staphylococcus aureus by Bacitracin or Mupirocin. Infect Control Hosp Epidemiol 1996. [DOI: 10.1017/s0195941700006548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractThe in vitro activities of bacitracin and mupirocin were compared for seven different strains of methicillin-resistant Staphylococcus aureus. Six of seven strains showed bacitracin minimum inhibitory concentrations (MICs) of 0.5 to 1.0 units/mL, and all seven had mupirocin MICs of 0.5 to 2 μg/mL. Time-kill studies revealed 2.6- to 4.5-log reduction in 24 hours with strains susceptible to bacitracin (4 units/mL) and 0 to 2.2 reduction with mupirocin (16 μg/mL). Bacitracin should be considered further for in vivo studies because of enhanced bacteriocidal effect and lower cost.
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