Mupirocin Ointment Research Articles

Decolonization of orthopedic surgical team S. aureus carriers: impact on surgical-site infections

BackgroundOrthopedic surgical-site infection (SSI), mostly due to S. aureus, is recognized as a major adverse event. This research aims to verify the usefulness of surgical team decolonization in order to reduce the risk of surgical-site infection.Materials and methodsWe performed swabs of both nares and oropharynx to identify S. aureus carriers among orthopedic team members who consented to cooperate with the study. Carriers were treated with local application of mupirocin ointment.ResultsRetrospective study of 1,000 consecutive patients operated before surgical team decolonization showed 6‰ SSIs. Of the 300 cases considered after decolonization, none developed SSI.ConclusionsThough we are aware that more data need to be collected, this work might be relevant for the introduction of a new preventive protocol.

Interventions for preventing infectious complications in haemodialysis patients with central venous catheters

Central venous catheters (CVC) continue to play a prominent role in haemodialysis vascular access with 46% to 70% of patients commencing haemodialysis via a CVC. CVC access is associated with catheter-related infections, increased patient hospitalisations and death due to infection. A variety of interventions are used to prevent CVC infection. To evaluate the benefits and harms of prophylactic topical antimicrobials, topical antiseptics, medicated and non-medicated dressings on infectious complications among haemodialysis patients with CVC. We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and reference lists of articles without language restriction. We included randomised controlled trials (RCTs) and quasi-RCTs investigating any intervention that prevented infectious complications among haemodialysis patients with CVC. We excluded antimicrobial impregnated CVC or CVC using locking solutions with antimicrobial properties. Two authors assessed study quality and extracted data. Dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI) and continuous outcomes as mean differences (MD). Ten studies (786 patients) were included. Mupirocin ointment reduced the risk of catheter-related bacteraemia (RR 0.17, 95%CI 0.07 to 0.43) and had a significant effect on catheter-related infections caused by S. aureus. The risk of catheter-related bacteraemia was reduced by polysporin (RR 0.40, 95%CI 0.19 to 0.86) and povidone-iodine ointment (RR 0.10, 95%CI 0.01 to 0.72). Subgroup analysis suggested mupirocin (RR 0.12, 95%CI 0.01 to 2.13) and povidone-iodine ointment (RR 0.84, 95%CI 0.24 to 2.98) had no effect on all-cause mortality while polysporin ointment showed a significant reduction (RR 0.22, 95%CI 0.07 to 0.74). Mortality related to infection was not reduced by mupirocin, polysporin or povidone-iodine ointment. Topical honey did not reduce the risk of exit site infection (RR 0.45, 95%CI 0.10 to 2.11) or catheter-related bacteraemia (RR 0.80, 95%CI 0.37 to 1.73). Transparent polyurethane dressing compared to dry gauze dressing did not reduce the risk of CVC or exit site infection, or catheter-related bacteraemia. Mupirocin ointment appears effective in reducing the risk of catheter-related bacteraemia. Insufficient reporting on mupirocin resistance was noted and needs to be considered in future studies. A lack of high quality data on the routine use of povidone-iodine ointment, polysporin ointment and topical honey warrant larger RCTs. Insufficient data were available to determine which dressing type (transparent polyurethane or dry gauze dressing) has the lowest risk of catheter-related infections.

Treatment of Staphylococcus aureus Colonization in Atopic Dermatitis Decreases Disease Severity

Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Pediatrics. 2009;123(5). Available at: www.pediatrics.org/cgi/content/full/123/5/e808PURPOSE OF THE STUDY. To determine the rate of methicillin-resistant Staphylococcus aureus (MRSA) colonization in children with moderate-to-severe atopic dermatitis (AD) and to investigate the use of bleach baths and intranasal mupirocin treatment in management.STUDY POPULATION. Patients (N = 31) 6 months to 17 years of age with moderate-to-severe AD and signs of bacterial skin infection were recruited from a dermatology clinic in Children's Memorial Hospital (Chicago, IL).METHODS. This was a randomized, investigator-blinded, placebo-controlled study. All patients were initially treated with cephalexin for 14 days and were then assigned randomly to receive intranasal mupirocin ointment (versus petrolatum placebo) twice daily for 5 days per month and to use one half cup of bleach (versus placebo water) in 40 gallons of bathwater for soaking for 5 to 10 minutes twice weekly. Treatment was undertaken for 3 months. The primary outcome measure was the Eczema Area and Severity Index score.RESULTS. S aureus was cultured from 81% of the nares and 87% of lesional skin samples, and the prevalence of MRSA was 4% of nasal cultures and 7.4% of skin cultures. Treated subjects, compared with control subjects, showed significantly greater mean reductions from baseline in Eczema Area and Severity Index scores at the 1-month and 3-month visits (P = .004). The improvement was attributable to score changes for body areas that had been submerged in the dilute bleach baths (score change at 3 months: treated: −4.9; placebo: −0.9; P = .0005).CONCLUSIONS. The authors concluded that chronic use of dilute bleach baths with intermittent intranasal application of mupirocin ointment decreased the clinical severity of AD in patients with clinical signs of secondary bacterial infections and that these patients did not have increased susceptibility to MRSA.REVIEWER COMMENTS. Noting the significant role of S aureus in the etiology of AD (as reviewed above), the use of bleach baths has been recommended for many years; however, study of the approach has been lacking. Clinicians must recognize that the approach here was targeted to a specific population (moderate-to-severe AD with superinfection) and more than just bleach baths were used (initial cephalexin treatment and also mupirocin and emollient/antiinflammatory drug therapies). While we await additional studies on the efficacy and safety (including promotion of resistance) of the studied approach, the lesson here includes the utility of a multifaceted approach to AD management that addresses infection.

MRSA Decolonization and Brown Bath Water

To the Editors: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of skin infections. Management of recurrent skin lesions caused by MRSA is challenging and optimal prevention strategies have not been established.1 Decreasing bacterial colonization of the skin has been a widely used strategy, although decolonization regimens vary by physician.2 Chlorhexidine gluconate, hexachlorophene, and household bleach (sodium hypochlorite) have been recommended for use during bathing or showering to help decolonize MRSA on skin surfaces. We recently participated in the medical care of a child with recurrent skin infections in which the family mistakenly used 2 of the above agents (sodium hypochlorite and a chlorhexidine product) simultaneously during the child's bath. Use of these 2 agents together created a color change in the bath water. A 2-year-old girl was seen with a history of recurrent purulent lesions on her lower extremities and perineal area. No cultures of these lesions had previously been obtained. In the clinic, the child was asymptomatic. Cultures of the child's nose and groin were obtained. A prescription for intranasal mupirocin ointment for topical use was given to the mother, as were instructions for the use of household bleach, 1 teaspoon per gallon of water, in the child's bath. When culture results returned showing both methicillin-susceptible S. aureus and MRSA, the mother was contacted. The mother reported that the child's bath water turned brown soon after she began using the sodium hypochlorite (bleach). Upon further questioning, the mom indicated that she was also using another product during the child's bath. This product was determined to contain chlorhexidine gluconate. It was recommended that the mother discontinue the chlorhexidine-containing product and use bleach only. Once the mother stopped using both agents, the bath water no longer turned brown. Reportedly, the brown bath water had not caused any staining or discoloration of the child's skin, bath fixtures, or washcloths. Although the authors are unaware of any pediatric literature involving the simultaneous use of chlorhexidine products and sodium hypochlorite in the management of children with recurrent MRSA infections, there are articles in the dental literature about brown discoloration when “bleaching” teeth with these agents.3,4 The combination of chlorhexidine and sodium hypochlorite can form a precipitate (brown flocculate).3,4 The authors also found reference to brown discoloration when examining the 2008 Data Sheet (package insert) from HiBi (chlorhexidine gluconate 2% wt/vol isopropyl alcohol 70% vol/vol, Mölnlycke Health Care, Manchester, UK). The package insert warns “Do not use chlorhexidine containing products in conjunction with or in area where cleaning agents containing bleach have been used as permanent brown stains can develop on fillings, fixtures, and clothing.” Hibiclens, a frequently used US product containing chlorhexidine gluconate, (Mölnlycke Health Care, Norcross, GA), has a warning in the package insert about using chlorhexidine and chlorine bleach together in the laundry (possible staining). The Hibiclens package insert recommends switching to a peroxide-type bleach to eliminate the reaction and “minimize possible staining.” Chlorhexidine gluconate, when used as a hand cleanser, bonds to a protein on the skin and has residual activity over a relatively long (hours) period of time. Chlorhexidine also bonds to fabrics, especially cotton (Hibiclens package insert, Mölnlycke Health Care, Norcross, GA). Physicians and other healthcare providers need to be aware of a chemical interaction which may occur between chlorhexidine gluconate and sodium hypochlorite and the need to advise patients and families to avoid the simultaneous use of these 2 agents for personal hygiene and laundry. Dennis L. Murray, MD, FAAP, FIDSA Department of Pediatrics Medical College of Georgia Augusta, GA Weng Man Lam, PharmD University of Georgia College of Pharmacy Medical College of Georgia Department of Pharmacy Augusta, GA

Impact of a Methicillin-Resistant Staphylococcus Aureus Active Surveillance Culture Protocol on Mupirocin Prescribing

Background To identify patients colonized with methicillin-resistant Staphylococcus aureus (MRSA), an active surveillance culture (ASC) protocol has been in place since March 2007. Decolonization with mupirocin ointment is not recommended but may be attempted after a positive MRSA screen. Objective Assess the impact of an inpatient ASC protocol on prescribing of mupirocin nasal ointment for decolonization before and after protocol implementation. Methods A retrospective review of mupirocin inpatient prescribing and outpatient clinic requests from March 2006 through February 2007 (1 year before ASC implementation) and from March 2007 through February 2008 (1 year after ASC implementation) was conducted. Cultures for MRSA after decolonization were evaluated. Results During the 24 months reviewed, 38 inpatients received mupirocin (18 before and 20 after ASC). Only 14 patients (37%) had a follow-up nasal swab (5 before and 9 after ASC). Of these patients, 5 (36%) had a positive nasal swab after the initial decolonization attempt. Ten patients (26%) had at least 1 clinical culture positive for MRSA after the initial decolonization (7 before and 3 after ASC). Outpatient requests for mupirocin increased 2.5-fold after ASC implementation. Sixty percent of the requests were not appropriate. Conclusion After implementation of the ASC protocol, there was no change in mupirocin prescribing for decolonization in the inpatient setting. However, outpatient requests—most of which were not indicated—increased. Success of decolonization cannot be assessed because follow-up nasal screening was not universally performed.

Review: intranasal mupirocin ointment reduces Staphylococcus aureus infections in nasal carriers

Does mupirocin nasal ointment reduce Staphylococcus aureus infections in patients who are nasal carriers of S aureus ? Included studies compared intranasal mupirocin ointment with placebo, no treatment, or an...

Surface disinfection properties of the combination of an antimicrobial peptide, ranalexin, with an endopeptidase, lysostaphin, against methicillin-resistantStaphylococcus aureus(MRSA)

To characterize the antibacterial synergy of the antimicrobial peptide, ranalexin, used in combination with the anti-staphylococcal endopeptidase, lysostaphin, against methicillin-resistant Staphylococcus aureus (MRSA), and to assess the combination's potential as a topical disinfectant or decolonizing agent for MRSA. MRSA causes potentially lethal infections, and pre-operative patients colonized with MRSA are often treated with chlorhexidine digluconate and mupirocin cream to eradicate carriage. However, chlorhexidine is unsuitable for some patients, and mupirocin resistance is increasingly encountered, indicating new agents are required. Using an ex vivo assay, ranalexin and lysostaphin tested in combination reduced viable MRSA on human skin to a greater extent than either compound individually. The combination killed bacteria within 5 min and remained effective and synergistic even in high salt and low pH conditions. The combination is active against MRSA on human skin and under conditions that may be encountered in sweat. Although the exact mechanism of activity remains unresolved, considering its specific spectrum of activity, fast killing kinetics and low likelihood of resistance arising, the combination of ranalexin with lysostaphin warrants consideration as a new agent to eradicate nasal and skin carriage of Staph. aureus, including MRSA.

Exit-Site Care in Austrian Peritoneal Dialysis Centers — a Nationwide Survey

Catheter-associated infections markedly contribute to treatment failure in peritoneal dialysis (PD) patients. There is much controversy surrounding prophylactic strategies to prevent these infections. In this nationwide multicenter study we analyzed strategies to prevent catheter-associated infections as performed in Austrian PD centers in 2006. A questionnaire was sent to all 23 PD centers in Austria. Ten different catheter models were used in the 332 patients being treated in the 23 Austrian PD centers. Systemic antibiotics prior to catheter placement were given by 17 of the 23 PD centers (glycopeptides, n = 7; cephalosporins, n = 10). Nasal swabs were taken preoperatively by 17 PD centers; nasal Staphylococcus aureus carriers were treated prophylactically with mupirocin cream in 15 of these centers. Dressing change was routinely performed in 318 of 332 chronic PD patients (nonocclusive film dressing, n = 58; gauze dressing, n = 260). Disinfectants for chronic exit-site care included povidone iodine (n = 155), sodium hypochlorite (n = 31), povidone iodine + sodium hypochlorite together (n = 102), and octenidine dihydrochloride/phenoxyethanol (n = 17). Water + non-disinfectant soap or 0.9% sodium chloride was administered as a cleansing agent to the exit site by 27 patients. Routine S. aureus screening (nasal and/or exit-site swabs) in chronic PD patients was performed in 12 PD centers; carriers were treated with mupirocin cream in 11 of these centers. Dialysis staff members were screened for S. aureus in 8 PD centers and spouses were screened for S. aureus in 5 PD centers. The overall exit-site infection rate was 1 episode/43.9 patient-months, tunnel infection rate was 1 episode/88.9 patient-months, and peritonitis rate was 1 episode/51.0 patient-months. Patients of centers that have installed a prophylaxis protocol for treating S. aureus carriers had lower mean infection rates compared with those not using such a protocol. Various individual prophylactic strategies are used to prevent catheter-associated infections in Austrian PD centers. Infection rates are within the range reported in the literature. There is still scope for improvement in some centers (e.g., by establishing a prophylaxis protocol).

Treatment of Staphylococcus aureus Colonization in Atopic Dermatitis Decreases Disease Severity

The goals were to determine the prevalence of community-acquired methicillin-resistant Staphylococcus aureus colonization in patients with atopic dermatitis and to determine whether suppression of S aureus growth with sodium hypochlorite (bleach) baths and intranasal mupirocin treatment improves eczema severity. A randomized, investigator-blinded, placebo-controlled study was conducted with 31 patients, 6 months to 17 years of age, with moderate to severe atopic dermatitis and clinical signs of secondary bacterial infections. All patients received orally administered cephalexin for 14 days and were assigned randomly to receive intranasal mupirocin ointment treatment and sodium hypochlorite (bleach) baths (treatment arm) or intranasal petrolatum ointment treatment and plain water baths (placebo arm) for 3 months. The primary outcome measure was the Eczema Area and Severity Index score. The prevalence of community-acquired methicillin-resistant S aureus in our study (7.4% of our S aureus-positive skin cultures and 4% of our S aureus-positive nasal cultures) was much lower than that in the general population with cultures at Children's Memorial Hospital (75%-85%). Patients in the group that received both the dilute bleach baths and intranasal mupirocin treatment showed significantly greater mean reductions from baseline in Eczema Area and Severity Index scores, compared with the placebo group, at the 1-month and 3-month visits. The mean Eczema Area and Severity Index scores for the head and neck did not decrease for patients in the treatment group, whereas scores for other body sites (submerged in the dilute bleach baths) decreased at 1 and 3 months, in comparison with placebo-treated patients. Chronic use of dilute bleach baths with intermittent intranasal application of mupirocin ointment decreased the clinical severity of atopic dermatitis in patients with clinical signs of secondary bacterial infections. Patients with atopic dermatitis do not seem to have increased susceptibility to infection or colonization with resistant strains of S aureus.

Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers

You might not know the name Staphylococcus aureus but you have probably heard of MRSA. Staphylococcus aureus is the bacterium and it is found in about one in every three people, mainly in the nose. Normally, it doesn't make you ill but if your resistance is low, it can cause an infection. The resistance of most patients in hospitals is very low. In addition, during their stay in hospital several procedures might be performed on them, which increase their chance of picking up a bacterium. For example, they might have surgery or have a catheter inserted. If a patient becomes infected by a bacterium while in hospital, we call it a hospital acquired infection, and there are two ways that this can happen. First, patients can be infected by bacteria from other patients, for example via the hands of health care workers, or by other people such as visitors. If the infection comes from another patient, this is called cross-infection. Second, patients can be infected by their own bacteria. Traditionally, the control of Staphylococcus aureus has been focused on preventing cross-infection between patients. However, it has been shown repeatedly that a large proportion of hospital acquired infections originate from the patient's own bacteria. Research has shown that having Staphylococcus aureus in their nose is a risk factor for subsequent infection in various groups of patients. Intanasal antibiotic treatment with mupirocin ointment is often used to deal with this, by eradicating nasal Staphylococcus aureus. Trials have been done to look at whether this treatment does lead to fewer infections after surgery but, on their own, these did not provide a clear answer and we wondered if these studies might have looked at the wrong group of people, namely all patients. We wanted to focus on patients that were known to have Staphylococcus in their nose, because we think that these are the people who are at risk for getting a Staphylococcus aureus infection from their bacteria. [1] People who don't have this bacterium cannot infect themselves with it. We did a literature search to find randomised trials that studied the effects of mupirocin nasal ointment on the number of Staphylococcus aureus infections. We wanted trials that had divided the patients into two treatment groups: those who would get treatment with mupirocin and those who would not be given this. In the last group, the “control” patients could receive a placebo or no treatment. We identified nine eligible studies with a total of nearly 3400 participants, and we were able to pool the results of these studies in a meta-analysis to get an especially powerful statistical answer. If you are interested in the effect of mupirocin on time to infection, mortality, adverse events and number of infections caused by other micro-organisms than Staphylococcus aureus, you should definitely read the full review. But, in summary, we have found a real effect of mupirocin on the total number of Staphylococcus aureus infections, in a wide variety of patients. The number of people who got an infection was halved. Up until now, although mupirocin is used for many patients, it is not routinely used in some hospitals. This is mainly because of concerns about the development of resistance to the antibiotic and the absence of convincing evidence that it really does reduce the infection rate. However, we have found that short-term use of intranasal mupirocin ointment does not seem to be associated with resistance, and that it does reduce infections. In our opinion, intranasal mupirocin should now be considered for use more widely, for patients who are known to be nasal carriers of Staphylococcus, who are in hospital for dialysis, surgery or other reasons.

A Double‐Blind, Randomized, Controlled Trial of Topical Polysporin Triple Compound Versus Topical Mupirocin for the Eradication of Colonization with Methicillin‐Resistant Staphylococcus aureus in a Complex Continuing Care Population

Intranasal mupirocin or Polysporin Triple (PT) ointment (polymyxin B, bacitracin, gramicidin), in combination with chlorhexidine body washes, have been used for eradicating methicillin-resistant Staphylococcus aureus (MRSA), but no comparative studies have been done. A double-blind, randomized, controlled clinical trial to compare the efficacy of mupirocin versus PT ointment in combination with chlorhexidine body washes in eradicating MRSA carriage was conducted. Asymptomatic MRSA carriers, medically stable and at least 18 years of age who were patients on medical wards, received twice daily application of either mupirocin or PT ointment to the anterior nares plus once daily 2% chlorhexidine body washes for seven days. Follow-up swabs from multiple sites using broth enrichment were conducted at 48 h, and one, two, four, eight and 12 weeks. Of 103 patients eligible for analysis (54 mupirocin; 49 PT), no significant differences between the two groups with respect to baseline demographics, risk factors for MRSA or MRSA colonization sites were noted. At 48 h, 35 of 54 (65%) patients in the mupirocin group versus 15 of 49 (31%) in the PT group (P=0.001) were found to be MRSA negative at all sites. Significant differences were observed at one and two weeks but were not maintained at other intervals. In those with complete microbiological follow-up, MRSA eradication at all sites occurred in 12 of 39 (30.8%) mupirocin- and one of 36 (2.8%) PT-treated patients (P=0.001). Both agents demonstrated poor efficacy and PT was significantly less efficacious than mupirocin at 12 weeks in eradicating MRSA from all sites.

A 7-year-old Girl with a Pruritic Facial Eruption

<P><I>Editor’s note: Each month, this department features a discussion of an unusual diagnosis in genetics, radiology, or dermatology. A description and images are presented, with the diagnosis and an explanation of how the diagnosis was determined following. As always, your comments are welcome.</I></P> <P>A 7-year-old girl was evaluated for a pruritic facial eruption that was present for 6 months. The eruption began on her right cheek. She was diagnosed with eczema and treated with hydrocortisone 2.5% ointment with initial improvement then worsening. Since that time, she was treated with multiple topical therapies, most of which also temporarily improved the eruption. These therapies included aclometasone 0.05% cream, clotrimazole 1% cream, mupirocin ointment, and most recently, clotrimazole 1%/betamethasone dipropionate cream. In addition, she completed a 10-day course of oral clarithromycin without improvement in the eruption. The patient’s past medical history was otherwise unremarkable.</P><H4>ABOUT THE AUTHORS</H4><P>Clara Filice, MD, MPH, and Sarah L. Chamlin, MD, are with the Division of Dermatology, Children’s Memorial Medical Center, Northwestern University, Chicago, Illinois.</P><P>Dr. Filice and Dr. Chamlin have disclosed no relevant financial relationships.</P>

A Case Report of Generalized Pustulosis With Systemic Manifestations Requiring Burn Intensive Care Unit Admission

Not infrequently patients are transferred to a burn center with the diagnosis of toxic epidermal necrolysis (TEN). Not all cases of generalized erythema and skin sloughing represent TEN. Acute generalized pustular psoriasis (AGPP) of the von Zumbusch type and acute generalized exanthematic pustulosis (AGEP) are two rare skin diseases that can also present with widespread erythema and skin sloughing. We present the case of a 55 year old morbidly obese woman with a history of severe psoriatic arthritis treated in our burn unit for generalized pustulosis, erythema, and skin sloughing. This was accompanied by respiratory failure, hypotension, acute renal failure, and elevated direct bilirubin. Skin biopsy narrowed the differential diagnosis to AGPP and AGEP. Her skin sloughing was treated as second degree burns with petrolatum gauze and mupirocin ointment. She required intubation, aggressive fluid resuscitation and inotropic support. She recovered with these measures over the course of 1 week. Like TEN, AGPP, and AGEP can involve the skin to an extent requiring burn intensive care admission. Patients can present on rare occasions with multi-system failure. We would like to raise the awareness of burn specialists regarding these rare diseases. They should be distinguished from TEN, as they tend to have better prognosis than TEN and their management can be different.

Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers

Staphylococcus aureus (S. aureus) is the leading nosocomial (hospital acquired) pathogen in hospitals throughout the world. Traditionally, control of S. aureus has been focused on preventing cross-infection between patients, however, it has been shown repeatedly that a large proportion of nosocomial S. aureus infections originate from the patient's own flora. Nasal carriage of S. aureus is now considered a well defined risk factor for subsequent infection in various groups of patients. Local antibiotic treatment with mupirocin ointment is often used to eradicate nasal S. aureus. To determine whether the use of mupirocin nasal ointment in patients with identified S. aureus nasal carriage reduced S. aureus infection rates. We searched the Cochrane Wounds Group Specialised Register (May 2008), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2 2008), MEDLINE (1950 to May 2008), EMBASE (1980 to May 2008) and CINAHL (1982 to May 2008). To identify unpublished trials, abstract books from major scientific meetings (ICAAC, ESCMID and SHEA) were handsearched, researchers and manufacturers of mupirocin were contacted and other electronic databases were searched (SIGLE, ASLIB Index, mRCT, USA Clinical Trials). Randomised controlled trials (RCTs) comparing nasal mupirocin with no treatment or placebo or alternative nasal treatment in the prevention of S. aureus infections in nasal S. aureus carriers were included. Titles, abstracts and full-text articles of studies retrieved from the search process were independently assessed by two authors for inclusion. From included studies a data extraction form was made and the quality of the trial was assessed. The primary outcome was the S. aureus infection rate (any site). Secondary outcomes were time to infection, mortality, adverse events and infection rate caused by micro-organisms other than S. aureus. Nine RCTs involving 3396 participants met the inclusion criteria. Patient populations varied and several types of nosocomial S. aureus infection were described including bacteraemia, exit-site infections, peritonitis, respiratory tract infections, skin infections, surgical site infections (SSI) and urinary tract infections. After pooling the eight studies that compared mupirocin with placebo or with no treatment, there was a statistically significant reduction in the rate of S. aureus infection associated with intranasal mupirocin (RR 0.55, 95% CI 0.43 to 0.70).A planned subgroup analysis of surgical trials demonstrated a significant reduction in the rate of nosocomial S. aureus infection rate associated with mupirocin use (RR 0.55, 95% CI 0.34 to 0.89) however this effect disappeared if the analysis only included surgical site infections caused by S. aureus (RR 0.63, 95% CI 0.38 to 1.04), possibly due to a lack of power. The infection rate caused by micro-organisms other than S. aureus was significantly higher in patients treated with mupirocin compared with control patients (RR 1.38 95% CI 1.118 to 1.72). In people who are nasal carriers of S. aureus, the use of mupirocin ointment results in a statistically significant reduction in S. aureus infections.

Unilateral Eyelid Discoid Lupus Erythematosus

To the Editor: Discoid lupus erythematosus (DLE) involving palpebral areas is estimated to occur in up to 5% of all patients with mucocutaneous DLE.1 These patients typically present with bilateral eyelid involvement and other associated mucocutaneous DLE lesions. Solely unilateral eyelid DLE is exceedingly rare and more commonly associated with delayed diagnosis and potential increased morbidity. We present a patient with unilateral eyelid DLE associated with madarosis, scarring, and mucosal involvement. A 38-year-old, otherwise healthy, woman presented with a 5-year history of an enlarging left lower eyelid lesion associated with pain, edema, and epiphora (Fig. 1). She denied other mucocutaneous lesions, loss of visual acuity, or constitutional symptoms. Previous therapies had resulted in minimal response and included topical triamcinolone 0.1% ointment, mupirocin ointment, and tobramycin plus dexamethasone eyedrop solutions. Physical examination revealed an indurated, erythematous, scaly plaque of the outer aspect of the left lower eyelid. Significant madarosis, early entropion, contiguous erythema, and edema of the inferior palpebral conjunctiva were also noted. No symblepharon or other ocular abnormality was detected on slit lamp and funduscopic examination. Ancillary studies including complete blood cell count, C3, C4, CH50, sedimentation rate, creatinine, urine analysis, antinuclear antibody, anti-dsDNA, rheumatoid factor, anti-ribonucleoprotein, anti-Sm, anti-Ro, and anti-La were negative or within normal limits. Histological evaluation of a 3-mm lesional punch biopsy specimen revealed an interface dermatitis associated with follicular involvement, superficial and deep perivascular lymphocytic infiltrate, increased dermal mucin confirmed with colloidal iron stain, and significant thickening of the epidermal and adnexal basement membrane confirmed with periodic acid-Schiff stain. Direct immunofluorescence evaluation of a 3-mm punch biopsy obtained from lesional skin revealed dense granular immunoglobulin M, C3, weaker immunoglobulin G, and C5b-9 deposits along the epidermal and adnexal basement membrane zone, confirming the diagnosis of DLE (Figs. 2A, B).FIGURE 1: Involving the outer aspect of left lower eyelid, physical examination showed an indurated, pink, erythematous, scaly plaque. Significant madarosis, early entropion, contiguous erythema, and edema of the inferior palpebral conjunctiva were also noted.FIGURE 2: A, Routine histological examination of lesional skin punch biopsy showed a interface dermatitis with hyperkeratosis, few dyskeratotic keratinocytes, thickened epidermal and adnexal basement membrane zones, increased superficial and deep mucin, and perifollicular sebaceous lymphocytic infiltrate. B, On direct immunofluorescence examination of lesional skin punch biopsy, immunoglobulin M, immunoglobulin G, and C3 heavy and thick granular deposition along the epidermal and adnexal basement membrane zone were noted. Few cytoid elements were noted. Indirect immunofluorescence showed no circulating antiepithelial antibodies.She was placed on 40-mg prednisone with a tapering-off regimen for more than 4 months. Mycophenolate mofetil 1 g twice daily and hydroxychloroquine 200 mg twice daily were concomitantly initiated as a corticosteroid-sparing therapy. On 5-month follow-up, significant improvement was noted while she continues on corticosteroid-sparing adjuvants. Eyelid involvement by DLE lesions has significant morbidity including madarosis, ectropion, entropion, scarring, cicatrizing conjunctivitis with symblepharon formation, and eventually blindness.2 Furthermore, DLE lesions that present solely on the eyelids frequently lack the typical clinical morphologic findings of this form of chronic cutaneous lupus erythematosus, imposing a diagnostic challenge and potential delayed therapy.3 Thus, awareness of this atypical presentation of DLE along with adequate sampling including the deep dermis and subcutis for both routine histology and direct immunofluorescence evaluation is crucial for accurate clinical pathologic correlation. Carlos Ricotti, MD University of Miami L. Miller School of Medicine Department of Dermatology Miami FL Elaine Tozman, MD University of Miami L. Miller School of Medicine Division of Rheumatology Miami FL Anthony Fernandez, MD, PhD University of Miami L. Miller School of Medicine Department of Dermatology Miami FL Carlos H. Nousari, MD Dermpath Diagnostics South Florida Pompano Beach FL // University of Miami L. Miller School of Medicine Department of Dermatology Miami FL

Clinical Effectiveness of Ototopical Application of Mupirocin Ointment in Methicillin-Resistant Staphylococcus aureus Otorrhea

Methicillin-resistant Staphylococcus aureus (MRSA) otorrhea has become an increasing problem with regard to infection through the tympanic membrane perforation and postsurgical infection. In particular, dry ear, at the preoperative stage, is considered to be a crucial factor in surgery. We evaluated how to control MRSA otorrhea before and after ear surgery. Twenty-six patients having MRSA otorrhea were enrolled in the present study and randomly divided into 2 groups, namely, mupirocin ointment therapy for 16 patients and ofloxacin ear drops for 10 patients. Approximately 0.6 mg of mupirocin ointment was administered locally to the tympanic membrane and the promontory around and through the perforation with its adjacent external ear canal 1 to 4 times for 2 or 3 weeks at the clinic. On the other hand, ofloxacin ear drops were administered daily by the patients for 2 or 3 weeks at home. Complete elimination of MRSA from the ear was obtained in all patients of the mupirocin group. This showed a significant improvement (p < 0.001) as compared with the ofloxacin group (improvement + cure rate, 40%). Local application of mupirocin did not aggravate hearing acuity of any patients who were evaluated by pure-tone audiometry before and after treatment. The present findings first indicate that minimally essential application of mupirocin ointment is an extremely useful ototopical agent against MRSA otorrhea without ototoxicity.

A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections

Staphylococcus aureus (S. aureus) is an independent risk factor for orthopaedic surgical site infection (SSI). To determine whether a preoperative decolonization protocol reduces S. aureus SSIs, we conducted a prospective observational study of patients undergoing elective total joint arthroplasty (TJA) at our institution, with two control groups. The concurrent control group comprised patients of surgeons who did not participate in the intervention study. The preintervention control group comprised patients of participating surgeons who had undergone elective TJA during the year before the study. Patients in the intervention group were screened preoperatively for S. aureus by nasal swab cultures. S. aureus carriers were decolonized with mupirocin ointment to the nares twice daily and chlorhexidine bath once daily for 5 days before surgery. All 164 of 636 participants (26%) who tested positive completed the decolonization protocol without adverse events and had no postoperative S. aureus SSIs at 1-year followup. In contrast, 1330 concurrent control patients had 12 S. aureus infections. If these infections had occurred in the 26% of patients expected to be nasal carriers of S. aureus at a given time, the infection rate would have been 3.5% (12 of 345) in the control group. In addition, the overall infection rate of the participating surgeons, including nonstaphylococcal infections, decreased from 2.6% during the preintervention period to 1.5% during the intervention period, translating to an adjusted economic gain of $231,741 for the hospital. The data suggest a preoperative decolonization protocol reduces S. aureus SSIs in patients undergoing TJA. Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Impact of preoperative screening for meticillin-resistant Staphylococcus aureus by real-time polymerase chain reaction in patients undergoing cardiac surgery

We report a significant reduction in the number of surgical site infections (SSIs) due to meticillin-resistant Staphylococcus aureus (MRSA) in patients undergoing cardiac surgery after the introduction of preoperative screening using a same-day polymerase chain reaction (PCR) test. This was an observational cohort study set in a cardiac surgery unit based in southwest England. We studied 1462 patients admitted for cardiac surgery between October 2004 and September 2006. The IDI MRSA PCR test was used preoperatively to screen 765 patients between October 2005 and September 2006. Patients identified as carriers were treated with nasal mupirocin ointment and topical triclosan for five days, with single-dose teicoplanin instead of flucloxacillin as perioperative antibiotic prophylaxis. The rate of SSI following cardiac surgery in this group was compared to 697 patients who underwent surgery without screening between October 2004 and September 2005. After introduction of PCR screening, the overall rate of SSI fell from 3.30% to 2.22% with a significant reduction in the rate of MRSA infections (relative risk reduction: 0.77; 95% confidence interval: 0.056-0.95). PCR screening combined with suppression of MRSA at the time of cardiac surgery is feasible in routine clinical practice and is associated with a significant reduction in subsequent MRSA SSIs.

Prevalence of Methicillin-Resistant &lt;I&gt;Staphylococcus aureus&lt;/I&gt; Among Orthopedic Patients at a Large Academic Hospital

Community-based methicillin-resistant Staphylococcus aureus (MRSA) contributes to postoperative surgical site infections, and it is therefore important to eliminate nasal carriage of MRSA before surgery. A total of 678 nasal swabs were performed on elective orthopedic patients undergoing surgery with the usage of metal implants. Thirty-eight specimens (5.6%) were positive for MRSA and 146 (21.5%) were positive for methicillin-sensitive S aureus (MSSA). A slow increase in the number of MSSA was noted between 2006 and 2007. Positive cases of MRSA nasal carriage were treated with nasal mupirocin ointment and chlorhexidine baths or showers for 5 days prior to surgery.

Universal Screening for Methicillin-Resistant &lt;emph type="ital"&gt;Staphylococcus aureus&lt;/emph&gt; at Hospital Admission and Nosocomial Infection in Surgical Patients

Experts and policy makers have repeatedly called for universal screening at hospital admission to reduce nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. To determine the effect of an early MRSA detection strategy on nosocomial MRSA infection rates in surgical patients. Prospective, interventional cohort study conducted between July 2004 and May 2006 among 21 754 surgical patients at a Swiss teaching hospital using a crossover design to compare 2 MRSA control strategies (rapid screening on admission plus standard infection control measures vs standard infection control alone). Twelve surgical wards including different surgical specialties were enrolled according to a prespecified agenda, assigned to either the control or intervention group for a 9-month period, then switched over to the other group for a further 9 months. During the rapid screening intervention periods, patients admitted to the intervention wards for more than 24 hours were screened before or on admission by rapid, multiplex polymerase chain reaction. For both intervention (n=10 844) and control (n=10 910) periods, standard infection control measures were used for patients with MRSA in all wards and consisted of contact isolation of MRSA carriers, use of dedicated material (eg, gown, gloves, mask if indicated), adjustment of perioperative antibiotic prophylaxis of MRSA carriers, computerized MRSA alert system, and topical decolonization (nasal mupirocin ointment and chlorhexidine body washing) for 5 days. Incidence of nosocomial MRSA infection, MRSA surgical site infection, and rates of nosocomial acquisition of MRSA. Overall, 10 193 of 10 844 patients (94%) were screened during the intervention periods. Screening identified 515 MRSA-positive patients (5.1%), including 337 previously unknown MRSA carriers. Median time from screening to notification of test results was 22.5 hours (interquartile range, 12.2-28.2 hours). In the intervention periods, 93 patients (1.11 per 1000 patient-days) developed nosocomial MRSA infection compared with 76 in the control periods (0.91 per 1000 patient-days; adjusted incidence rate ratio, 1.20; 95% confidence interval, 0.85-1.69; P = .29). The rate of MRSA surgical site infection and nosocomial MRSA acquisition did not change significantly. Fifty-three of 93 infected patients (57%) in the intervention wards were MRSA-free on admission and developed MRSA infection during hospitalization. A universal, rapid MRSA admission screening strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection. isrctn.org Identifier: ISRCTN06603006.