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

Bernhard Jahn,Annemarie Stroh,Trudy M Wassenaar

doi:10.1186/s13756-016-0124-5

Abstract

BackgroundGuidelines 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.MethodsThis 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.ResultsThe 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).ConclusionsThe 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s13756-016-0124-5) contains supplementary material, which is available to authorized users.

Highlights

Guidelines for the control of hospital-acquired MRSA include decolonization measures to end MRSA carrier status in colonized and infected patients
To overcome the limitations of MRSA decolonization of inpatients with short hospitalization duration, we developed a new strategy for an Integrated MRSA Management (IMM)
201 patients with a hospital stay of at least 7 days were chosen, which was the main inclusion criterion for the inpatient control group. These patients were at least 18 years of age and, identified as MRSA carriers, showed no symptoms of an acute MRSA infection. This resulted in a Full Analysis Set (FAS) of 201 patients for the inpatient control group, who received all decolonization procedures routinely used in the hospital, as described in the Additional file 1

Summary

Introduction

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). [4,5,6], reviewed in [7]) As part of these guidelines, decolonization of MRSA carriers is often recommended, since this can effectively reduce the risk of infection, in particular when performed prior to high-risk interventions such as surgery or central catheter insertion [8]. Universal decolonization of all patients has been shown to reduce bloodstream infections in an intensive care setting even more effectively in comparison to targeted decolonization of carriers only [9]. The microbiological follow-up of inpatients is omitted so that the carrier status of patients at discharge is uncertain

Methods

Results

Discussion

Conclusion