Nasal Ointment Research Articles

#2355 Eradication of Staphylococcus aureus carriage in patients undergoing peritoneal dialysis

Abstract Background and Aims Peritonitis is a common and serious complication of peritoneal dialysis (PD). A single episode of severe peritonitis or multiple peritonitis episodes frequently leads to diminished peritoneal ultrafiltration capacity, hospitalization, and a switch to hemodialysis. Prevention of infection is the mainstay for the reduction of peritonitis rate. According to the current guidelines, we use nasal antibiotic prophylaxis if patients are identified as nasal Staphylococcus aureus carriers on screening prior to PD beginning. Eradication of S. aureus Regular with nasal mupirocin reduces the rate of exit-site infections but has uncertain effects on the risk of peritonitis. The aim of this study was to evaluate the rate of S. aureus peritonitis in our cohort of patients receiving PD. Method A retrospective single-center study was conducted in a large Italian PD center. We reviewed all cases of bacterial peritonitis from 1999 to 2023. Demographic and clinical characteristics of the patients and microbiological features of the bacteria identified in cultures were extracted from electronic health record. From 2011, all patients were screened before surgery for Methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) with nares swabs. All patients with positive nasal colonization for MSSA and MRSA were treated with nasal mupirocin (nasal ointment twice daily for 5 consecutive days every 4 weeks) until eradication was confirmed by a nasal swab. According to our protocol, from 2011, screening for S. aureus carriage along peritoneal fluid culture was performed in all patients on PD with an episode of peritonitis to verify nasal colonization with S. aureus. The study was approved by the regional ethical committee of Emilia Romagna (507/2021/OSS/AOUMO SIRER ID 2845). Results Overall, 345 cases of peritonitis were reviewed in 214 patients who received peritoneal dialysis. In our center, the rate of peritonitis was 0.23 episodes/patient-year. After the introduction of nasal screening for S. aureus carriage, the episodes of S. aureus peritonitis decreased in frequency (0.0093 episodes/patient-year vs. 0.034 episodes/patient-year) and as absolute number (17.8% vs 3.6%; p = 0.001). No differences were observed in the rate of catheter removal in the two populations (p = 0.99). The age of 109 patients screened for S. aureus carriage was 64.1 ± 17 years. Males accounted for 58.9% and automated PD (APD) was chosen by 66% of the subjects. After an average period of 1.6 years from the start of PD, 7 patients experienced S. aureus peritonitis in the absence of exit-site or tunnel catheter infection. Nasal screening at the time of peritonitis showed that half of them were carriers of S. aureus and half were negative (one patient was not screened). Colonization from S. aureus was found in another 9 patients whose peritonitis was caused by a different type of bacteria (44% S. epidermidis, 33.3% Enterobacteriaceae, 11.1% Acinetobacter, and 11.1% culture-negative peritonitis). Conclusion Our data document that screening for S. aureus, along with other preventive measures, contributes to significantly reducing the rate of S. aureus peritonitis in patients screened and treated for S. aureus carriage at the time of PD start. Routine screening and the use of a mask during connection are required because recolonization occurs frequently in this population.

Surgical Site Infection Prevention Strategies in Cardiac Surgery: A Systematic Review

Background: Cardiac surgery becomes one of surgical procedure that has potential for develop several complications including surgical site infection (SSI). Despite the case is still very common, SSI can be regarded as the most preventable, especially when the treatment approach used, because there are many risk factors associated with the target. This systematic review aims to assess the effectiveness of interventions strategies used to reduce the incident of SSI in cardiac surgery. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines provide a standardized framework for conducting and reporting systematic reviews. A comprehensive search was conducted across major electronic databases, The following database were PubMed, Scopus and ProQuest. The inclusion criteria were clinical and a randomized control trial published between 2018 to 2023. The primary outcome measure was SSI rates. Results: The studies encompassed diverse perioperative intervention strategies, such as pre operative nasal ointment, pre operative showering and shaving, chlorhexidine mouthwash, and negative pressure therapy. In total, 436.762 articles regarding SSI prevention strategies in cardiac surgery were found in this study. However, around 7 articles that were met with the criteria of this study. Conclusion: Actions to reduce the incidence of SSI are carried out at all perioperative stages. The action taken was modifying the intervention and also using additional therapy carried out by health workers.

Prevention of surgical site infections: a personal odyssey

Prevention of surgical site infections: a personal odyssey

1232. Mupirocin Susceptibility of Staphylococcus aureus (SA), 2022: Is It Time for Change in MRSA Decolonization?

Abstract Background Nasal decolonization with mupirocin has been a commonly used strategy for the prevention of surgical site infections (SSIs) due to SA. We recently noted an increase in SSIs due to SA despite the use of mupirocin, including a case of post-operative mupirocin-resistant MRSA infection despite intranasal mupirocin. We therefore evaluated the mupirocin susceptibility of SA at Stamford Hospital to determine the optimal regimen for decolonization. Methods SA isolates were recovered from clinical and screening samples received in the microbiology laboratory from 8/1/2020 to 2/28/2022. Mupirocin susceptibility was determined using e-tests and a standardized inoculum on Mueller-Hinton agar. Isolates were categorized as “susceptible” (MuS) with minimum inhibitory concentrations (MIC) ≤4 mcg/ml or resistant (MuR) with MIC values ≥8mcg/ml. Resistant strains were further divided into low-level resistance, with MIC values from 8 to 256 mcg/ml, and high-level resistance, with MIC values >256/ml. SA isolates were identified and tested for susceptibility by usual Clinical Laboratory Standards Institute (CLSI) criteria. Results 223 unique SA isolates from 218 patients were tested. Patients ranged in age from newborn to 94 years. Twenty-four SA isolates (10.8%) were resistant to mupirocin (20 MRSA and 4 MSSA). Of the 24 MuR strains, 19 (79.2%) isolates demonstrated high-level resistance. MRSA strains were more likely to be resistant (22.5% were MuR) than MSSA strains (3.0% were MuR) (p< 0.001). MuR strains did not differ from MuS strains with respect to patient age, sex, race, site of isolation, infected versus colonized, community-acquired versus hospital-acquired or inpatient/out-patient location. Conclusion Preventing surgical site infections is challenging. Decolonization with mupirocin nasal ointment has been a common component of preoperative optimization. However, the emergence of resistance would render mupirocin suboptimal and other regimens might be preferred. In our study, less than 80% of MRSA strains were MuS. These findings are concerning and have led us to reevaluate our current decolonization strategy. In patients colonized with MRSA at high risk for infection (e.g. total joint replacement), intranasal povidone iodine may be preferable to mupirocin. Disclosures All Authors: No reported disclosures.

Comparative study of the specific activity of soft application drugs with vinpocetine

In modern neurology, the main component of successful treatment of cerebrovascular pathology is pharmacotherapy. At the same time, the arsenal of effective medicines of evidence-based medicine in this area is quite limited. Vinpocetine (Cavinton) is one of the drugs that effectively selectively corrects cerebral perfusion. The use of alternative ways of absorption of vinpocetine (rectal and nasal) in certain soft application dosage forms will allow to significantly increase the bioavailability of the medicinal substance, reduce the level of adverse reactions from its use and expand the pharmacotherapeutic arsenal of domestic effective neuroprotective drugs. Taking into account the above, the employees of the Department of Medicines Technology of Zaporizhzhia State Medical University, on the basis of complex physical-chemical, pharmacotechnological, rheological and biopharmaceutical research, proposed rational formulations and technologies of two new soft application dosage forms of vinpocetine – rectal suppositories on a lipophilic basis and nasal cream on an emulsion basis for the therapy of arterial hypertension of II–III stages with cerebrovascular complications, reduction of the manifestation of neurological and/or mental symptoms in various forms of cerebral blood circulation insufficiency, consequences of a stroke, transient ischemic attack, etc. The aim of the work is to study the specific activity of the proposed innovative application dosage forms of vinpocetine. Materials and methods. Nasal ointment containing 0.5 % vinpocetine on an emulsion basis and rectal suppositories with vinpocetine 0.01 g on a lipophilic carrier were used as the object of preclinical studies, which ensure optimal release of the active pharmaceutical ingredient. The study of the specific activity of the developed medicinal forms of vinpocetine was carried out on a model of acute cerebrovascular accident of the type of ischemic stroke. Vinpocetin tablets (Astrapharm, Ukraine), which are used in neurological practice quite effectively and over a long period of time, were used as a comparison drug. Results. The comparative results showed that the appointment of all studied drugs led to an increase in motor activity. In addition, the administration of medicinal forms of vinpocetine reduced the development of cognitive and cognitive disorders after acute disorders of cerebral blood circulation. It was found that the highest result was shown by the group of animals that received a course of vinpocetine intranasally. In the groups of animals that received vinpocetine for 4 days, markers of oxidative stress – aldehyde phenylhydrazones and ketone phenylhydrazones – were significantly reduced. The highest activity was demonstrated by the pharmaceutical form of vinpocetin, which was used intranasally for 4 days. The introduction of dosage forms of vinpocetine exerted an energizing effect, which was expressed in an increase in the level of macroergic phosphates. Evidently, vinpocetine has a direct positive effect on the three-carbon sections of the Krebs cycle and increases the production of adenosine triphosphate (ATP). At the same time, the vinpocetine nasal cream applied intranasally for 4 days demonstrated the greatest energizing activity. Conclusions. Preclinical studies of the developed application soft medicines with vinpocetine on the model of acute cerebrovascular accident type ischemic stroke experimentally confirmed the expressed neuroprotective activity of rectal suppositories and nasal cream with vinpocetine and it was found that the effectiveness of therapy with these application medicinal forms is demonstrably higher than that in comparison with oral tablet means.

Development and Validation of a Novel HPLC Method for the Determination of Ephedrine Hydrochloride in Nasal Ointment

A simple, precise, and cost-effective reverse phase ion pair chromatographic (RP-IP-HPLC) method was developed and validated for the determination of Ephedrine Hydrochloride in a nasal ointment. A simple and fast extraction protocol was developed for the effective recovery of the analyte, and for this purpose, Bromhexine Hydrochloride was used as the internal standard. The mobile phase consisted of MeOH, Sodium Lauryl Sulfate (SLS) 49.8 mM, triethylamine (ET3N) in the ratio of 65:34.6:0.4%, respectively, with pH = 2.20. The detection of the compounds was carried out at 206 nm, and we used a PDA detector. A short run time was achieved with retention times of 6.3 min and 9.8 min for ephedrine hydrochloride and the internal standard, respectively. The proposed method was validated according to ICH guidelines. Linearity was confirmed in the range of 50–150 μg/mL. Recoveries results were within the range of 98–102% and precision < 2% for the analyte in spiked blank matrix. Robustness testing was conducted via a fractional factorial experimental design. The method was found to fulfill the required specifications for specificity and stability for both standard solutions and samples, as well and applied to the determination of ephedrine hydrochloride in nasal ointments produced by the Greek Military Pharmaceutical Laboratories.

A randomized, placebo-controlled, double-blinded trial of MRSA throat carriage treatment, with either standard decolonization alone or in combination with oral clindamycin

BackgroundStaphylococcus aureus is a frequent colonizer of the human skin and mucous membranes but can also cause a variety of serious infections. Antimicrobial resistance is an increasing worldwide challenge and is mainly driven by an overuse of antimicrobials. To avoid the spread of methicillin-resistant Staphylococcus aureus (MRSA) in Denmark, the Danish Health Authority recommends decolonization treatment of MRSA carriers and their household contacts. Standard decolonization treatment includes chlorhexidine body wash and mupirocin nasal ointment, especially throat carriage is difficult to treat. The broad-spectrum antibiotic, clindamycin, is often added to the decolonization treatment, but there is currently low scientific evidence for this treatment.AimTo investigate whether the addition of clindamycin to the standard decolonization treatment increases decolonization success in MRSA throat carriers.MethodsA randomized, placebo-controlled, double-blinded trial, including patients ≥ 18 years, who tested MRSA positive in the throat after completing one standard decolonization treatment. All carriers included in the trial receive standard decolonization treatment and are randomized to treatment with either placebo or clindamycin capsules for 10 days. We plan to include 40 participants in each of the two treatment arms.DiscussionDue to the lack of consistent scientific evidence of clindamycin’s effect in MRSA decolonization and the worldwide urgent need to reduce the use of antibiotics, we judged that a 30% increase in the decolonization success rate in carriers treated with clindamycin is appropriate to justify prescribing clindamycin as part of the decolonization treatment of asymptomatic MRSA carriers.Trial registrationEudraCT number 2019-002631-29

Hand and nasal carriage of Staphylococcus aureus and its rate of recolonization among healthcare workers of a tertiary care hospital in Nepal.

BackgroundCarriers of Staphylococcus aureus among healthcare workers (HCWs) can spread the bacteria to patients and the environment, in addition to their own risk of infection.ObjectivesTo determine the prevalence of S. aureus carriers among HCWs and the rate of recolonization after decolonization therapy with mupirocin.MethodsNasal and hand swabs from HCWs of a tertiary care hospital in Nepal were cultured on mannitol salt agar and S. aureus isolated were identified using standard microbiological procedures. Detection of MRSA and mupirocin-resistant S. aureus (MupRSA) isolates were done phenotypically. Identified S. aureus carriers were decolonized with 2% mupirocin nasal ointment. Recolonization of the carriers was assessed monthly for the next 5 months.ResultsAmong the 213 HCWs, 18.3% were S. aureus carriers (35 nasal carriers, 4 both nasal and hand carriers, and no hand carriers). Overall, 9.4% of the HCWS were MRSA carriers and none were MupRSA carriers. After decolonization, 25.6% of them were recolonized and 50.0% of the recolonization was detected after 3 months of decolonization. All recolonized carriers had only MSSA strains (which colonized only nose), and none were recolonized with MupRSA.ConclusionsHCWs are frequent carriers of S. aureus and MRSA. Due to their continuous exposure to the hospital environment, they are at risk of colonization by this MDR organism. Regular screening and decolonization of HCWs working with high risk, vulnerable patients would reduce the risk of MRSA transmission from HCWs to patients.

Preoperative Colonization With Staphylococcus Aureus in THA Is Associated With Increased Length of Stay.

Preoperative Colonization With Staphylococcus Aureus in THA Is Associated With Increased Length of Stay.

783. Impact of Universal Decolonization on Intensive Care Unit Bloodstream Infections

Abstract Background Interventions used to reduce the incidence of hospital-acquired infections (HAIs) include hand hygiene, isolation, and decolonization. The routine use of chlorhexidine gluconate (CHG) and nasal mupirocin ointment has been shown to be an effective universal decolonization option to reduce bacterial transmission and prevent HAIs. The objective of this study is to compare the pre- and post-intervention of universal decolonization among ICU patients at Desert Regional Medical Center, an acute care Level II trauma center. Methods The first part of this study is a retrospective chart review of all ICU patients from June 2020 to August 2020. The second part of this research is a prospective study from December 2020 to March 2021. The prospective study will include all patients admitted to the ICU who completed the decolonization regimen of mupirocin for 5 days and daily CHG baths. In the intervention phase, all ICUs patients will be decolonized with nasal mupirocin twice daily for 5 days and CHG baths daily for the entire ICU stay. The primary outcome is the number of ICU bloodstream infections (BSIs). Secondary outcomes include the number of ICU-related central line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and ventilator associated pneumonia (VAP). An infection attributed to ICU stay is defined as an infection onset occurring more than 48 hours after ICU admission. Fisher’s exact and chi square test was used for the statistical analysis. Results A total of 130 patients were included in this study. Universal decolonization resulted in a reduction in overall ICU infections in the baseline group vs intervention group using a p-value of 0.05 (ICU-BSI 5 vs 4, p=0.73; CLABSI 2 vs 1, p=0.56; CAUTI 4 vs 2, p=0.41; VAP 23 vs 17, p=0.25). Conclusion Patients in the intervention group had a lower incidence of ICU infections compared to the baseline group. These findings suggest that universal decolonization may be an effective strategy in reducing ICU incidence rates of BSI, CLABSI, CAUTI, and VAP. Further studies need to be conducted to validate this finding with a greater population enrolled to achieve adequate power. Disclosures All Authors: No reported disclosures

887. Implementation of a Surgical Site Infection (SSI) Prevention Bundle: Patient Compliance and Experience

BackgroundAn evidence-based preoperative bundle including chlorhexidine gluconate (CHG) bathing, screening for S. aureus nasal carriage and decolonizing carriers with mupirocin was the standard of care for patients having total joint arthroplasty (TJA) at a VA medical center. We aimed to assess patient compliance with mupirocin and CHG, and characterize patient perceptions of barriers and facilitators to compliance.Compliance with CHG Bathing & Mupirocin By Methicillin-resistant S. aureus (MRSA) or Methicillin-susceptible S. aureus (MSSA) Colonization Status MethodsThe bundle for S. aureus colonized patients having TJA included nasal mupirocin ointment twice daily and daily CHG bathing for 5 days before surgery. The bundle for non-carriers included CHG bathing the day before and the morning of surgery. From 7/2018-10/2019, inpatients completed a 31-item survey following their TJA.Results73 patients completed the survey (~29% of the TJA population). 17 patients (23%) carried S. aureus & 56 patients (77%) were non-carriers. Patients reported high compliance with home use of CHG for the full number of days directed (88% when prescribed for 2 days; 71% when prescribed for 5 days; overall 85% used as prescribed; Figure). 7 (10%) patients reported CHG side effects, including burning or itchy/dry skin. 99% of patients reported willingness to use the CHG before a future surgery. Compliance with home use of mupirocin was lower (53% used as prescribed). Reported side effects included stinging, itching or dryness (N=2, 12%), unpleasant taste (N=2, 12%) & runny or stuffy nose (N=3, 18%). 100% of patients reported willingness to use mupirocin before a future surgery. Barriers to patient compliance with the bundle included forgetfulness and difficulty bathing daily. Facilitators to patient compliance included high facility compliance with S. aureus screening (100% patients reported), patient education regarding CHG and mupirocin use (95% patients recalled), and access to prescribed medications (100% patients received). Most patients (93%) reported no financial burden for mupirocin and 95% of patients reported no financial burden for CHG.ConclusionPatients reported high willingness to use the prevention bundle, yet mupirocin compliance was sub-optimal. Replacing patient-applied home mupirocin with nurse-applied day-of-surgery decolonization should be assessed in order to facilitate increased compliance.Disclosures All Authors: No reported disclosures

Prevalence of biocide resistance genes and chlorhexidine and mupirocin non-susceptibility in Portuguese hospitals during a 31-year period (1985–2016)

ObjectivesMethicillin-resistantStaphylococcus aureus (MRSA) remains a major human pathogen. MRSA decolonisation strategies frequently combine chlorhexidine baths and mupirocin nasal ointment. Although MRSA remains widespread in Portuguese hospitals, information regarding resistance to biocides and mupirocin is scarce. We evaluated the prevalence of biocide resistance genes and chlorhexidine and mupirocin non-susceptibility in a representative and well-characterised collection of MRSA isolated in Portuguese hospitals during a 31-year period (1985–2016). MethodsPrevalence of five biocide resistance genes (lmrS, mepA, sepA, qacAB and smr) was determined by PCR. Antibiotic susceptibility was assessed by disk diffusion and by MIC determination using broth microdilution (chlorhexidine) and Etest (mupirocin). ResultsChromosomal genessepA and mepA were detected in all isolates, while lmrS was found in 87.1%. The prevalence of plasmid-borne genes was significant for qacAB (22.4%), associated with the Iberian (ST247-I/IA) clone (P < 0.0001), and low for smr (1.0%) detected among isolates belonging to the ST239-III/IIIvariant clone. Chlorhexidine non-susceptibility (MIC ≥ 4 mg/L) was observed in two isolates belonging to the EMRSA-15 clone (ST22-IV). Non-susceptibility to mupirocin (MIC > 1 mg/L) was significant (15.4%; n = 31) and mainly found among isolates of the EMRSA-15 clone (P < 0.0001; n = 29). One isolate presented low-level mupirocin resistance (MIC = 32 mg/L), and two missense mutations N213D (A637G) and V588F (G1762T) were identified in the ileS gene. ConclusionConcerningly, we detected a high prevalence of biocide resistance genes and an association of mupirocin and chlorhexidine non-susceptibility with the dominant EMRSA-15 clone in Portuguese hospitals.

Preoperative decolonization and periprosthetic joint infections-A randomized controlled trial with 2-year follow-up.

Preoperative decolonization, especially of Staphylococcus aureus carriers, has been proposed to reduce periprosthetic joint infections (PJI), but the evidence-based consensus is still lacking and data on long-term outcomes is scarce. In a previous randomized, single-blinded trial, decolonization produced no significant reduction of surgical site infections in overall elective orthopedic surgery at 3-month follow-up. A 2-year follow-up was then performed to specifically detect the impact of decolonization on delayed-onset PJI (3-24 months after surgery). Between November 2015 and September 2017, 613 of 1318 recruited patients underwent prosthetic surgery. Individuals were allocated into either the S. aureus carrier group (34%, 207 of 613 patients) or the noncarrier group (406 of 613 patients), according to nasal swab screening results. Both groups were then randomized into intervention and control arms. In the S. aureus group, the intervention consisted of daily chlorhexidine showers and application of mupirocin nasal ointment twice a day for 5 days before surgery. In noncarriers, only chlorhexidine showers were prescribed. Sample size calculation was based on the initial trial for overall and not for the prosthetic surgery group. No PJI was found at 2years in either the carrier or in the noncarrier group. Therefore, no definite conclusion about the efficacy of preoperative decolonization to reduce PJI can be drawn. PJI proportions in this study were lower than described in the literature (mostly around 0.3%). Despite the insufficient sample size, this trial is the largest randomized trial on decolonization with a long-term follow-up, and results may be helpful for future meta-analyses.

Efficacy of Carragelose® Nasal Spray Impregnated Versus Mupirocin Ointment Impregnated Nasal Packs on Mucosal Healing after Endoscopic Sinus Surgery: A Double-Blind, Non-Randomized, Right-Left Side Comparison

ABSTRACTObjective: To determine the efficacy of carragelose® nasal spray versus mupirocin ointment impregnated nasal packs on postoperative mucosal healing among chronic rhinosinusitis with nasal polyposis (CRSwNP) patients after endoscopic sinus surgery (ESS).&#x0D; Methods:Design: Double-Blind, Non-Randomized, Right-Left Side ComparisonSetting: Tertiary Government Training HospitalParticipants: Fifteen (15) patients diagnosed with chronic rhinosinusitis with nasal polyposis (CRSwNP) who had ESS were included in the study. Nasal packs (Netcell®) impregnated with carragelose® nasal spray or mupirocin ointment were respectively applied in right and left nostrils. Postoperative mucosal healing was graded by a blinded consultant using the Lund-Kennedy Endoscopic Scoring System and Perioperative Sinus Endoscopy (POSE) scoring system.&#x0D; Results: Six patients (12 nasal sides) completed the study. Comparing nasal packs impregnated with carragelose® nasal spray mupirocin ointment, the carragelose® group had lower Lund- Kennedy median scores than the mupirocin group on the 7th post-operative day; and this was statistically significant (p = .027). There were no significant differences in Lund-Kennedy postoperative scores on days 4 (p = .217), 14 (p = .171) and 28 (p = .151).&#x0D; Conclusion: Carragelose® nasal spray impregnated nasal packs may be comparable with, and may be an alternative to mupirocin ointment impregnated nasal packs in terms of postoperative mucosal healing among ESS patients with CRSwNP.

Outbreak of community-acquired Staphylococcus aureus skin infections in an Australian professional football team

ObjectivesSkin and soft tissue infections commonly affect athletes and can lead to cluster outbreaks if not managed appropriately. We report the findings of an investigation into an outbreak of community-acquired Staphylococcus aureus infection in an Australian professional football team. DesignRetrospective cross-sectional study. MethodsNose, axilla, groin and throat swab were collected from 47 participants. MRSA and MSSA isolates underwent antibiotic susceptibility testing, binary typing and whole genome sequencing. Infection control practitioners (ICPs) investigated the training grounds for risk factors in the transmission of S. aureus. ResultsAlmost half of the participants (n=23, 48.9%) were found to be colonised with MSSA. An outbreak cluster of MRSA ST5 closely related to the fusidic acid-resistant New Zealand NZAK3 clone was identified in a group of four players. MSSA ST15 and MSSA ST291 strains were found to have colonised and spread between two and five players, respectively. All participants were advised to undergo decolonisation treatment consisting of 4% chlorhexidine body wash and mupirocin nasal ointment for ten days. The ICP team identified several unhygienic practices within the club’s shared facilities that may have played a role in the transmission of S. aureus. ConclusionsWe report for the first time a community-associated S. aureus outbreak involving the highly successful fusidic acid-resistant MRSA ST5 clone in a professional football club associated with inadequate hygiene procedures. Management and prevention of S. aureus relies heavily on hygiene education and adherence to personal and environmental hygiene practices and policies.

Moving Beyond Contact Precautions: Implementation of a Staphylococcus aureus Screening and Decolonization Program

Background:Staphylococcus aureus–colonized hospitalized patients are at risk for invasive infection and can transmit S. aureus to other patients in the absence of symptoms. Infection isolation precautions do not reduce the risk of infection in colonized patients and are untenable in health systems with high rates of S. aureus colonization. Objective: We implemented an inpatient S. aureus screening and targeted decolonization program across hospital campuses to reduce transmission and invasive infection. We screen and decolonize for methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) because MSSA makes up more than half of all S. aureus isolated from clinical cultures in our health system. Methods: All medicine, pediatrics, and transplant patients receive S. aureus nares culture at admission and upon change in level of care for medicine, and at admission and weekly for pediatrics and transplant patients. All S. aureus–colonized patients receive decolonization with nasal mupirocin ointment and chlorhexidine baths. Two implementation frameworks guide our processes for S. aureus screening and decolonization: the Consolidated Framework for Implementation Research, to evaluate factors affecting implementation at different levels of the health system, and the Dynamic Sustainability Framework, to account for iterative changes as the hospital setting and patient population change over time. Implementation interventions focus on education of patients and bedside nurses who perform S. aureus screening and decolonization; utilization of the electronic health record to identify patients for screening and/or decolonization and avoid human error; and introduction of a clinical nurse specialist to oversee the program and to provide iterative feedback. Results: At baseline, 21% of patients had S. aureus colonization, 20% of which was MRSA, and the MRSA bloodstream infection rate was 0.06 per 1,000 patient days. After program implementation, there was no change in S. aureus colonization and the MRSA bloodstream infection rate fell to 0.04 per 1,000 patient days. Screening compliance improved from 39% (N = 1,805) of eligible patients in the 6-month period before the introduction of the clinical nurse specialist to 52% (N = 2,024) after the introduction of the clinical nurse specialist. In the same periods, decolonization increased from 18.6% to 41% of eligible patients. Conclusions: We used 2 implementation frameworks to design our S. aureus screening and decolonization program and to make iterative changes to the program as it evolved to include new patient populations and different hospital settings. This resulted in a large-scale, sustainable, health system program for S. aureus control that avoids reliance on infection isolation precautions.Funding: NoneDisclosures: None

Effectiveness of an Alcohol-Based Nasal Antiseptic in Reducing MRSA Bacteremia in an Adult Intensive Care Population

Background: Hospitalized patients are at an increased risk of invasive infection with Staphylococcus aureus when colonized with the bacteria on admission. Rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are directly correlated with overall patient acuity, placing patients in intensive care areas at greatest risk. Universal decolonization with nasal antibiotic ointments has been shown to reduce the incidence of invasive MRSA in critically ill patients; however, debate remains regarding the long-term efficacy of this strategy and the possibility of developing antimicrobial resistance. An alcohol-based nasal antimicrobial may be an effective alternative. This study evaluated the effectiveness of a twice daily alcohol-based product in reducing the rate of MRSA bacteremia in an academic tertiary-care adult intensive care setting. Methods: Our study was an observational design with retrospective and prospective cohorts each consisting of 61 critical care beds. The baseline incidence of MRSA bacteremia was determined from a 7-month period preceding the implementation of the nasal antimicrobial. At implementation, each admission received an electronic order for an alcohol-based nasal antiseptic that was applied twice daily during the intensive care stay. The primary outcome was the incidence of MRSA bacteremia in each group. MRSA bacteremia was defined by the CDC NHSN criteria after review by an infection prevention nurse. The 2 test was used to compare the rates between the 2 groups, and P &lt; .005 was considered significant. Results: The study periods contained similar patient days, with 12,475 in the retrospective group and 12,733 in the prospective group. The rate of MRSA bacteremia in the retrospective cohort was 0.2404 compared to 0 in the prospective cohort. This rate change was statistically significant, with P &lt; .0001. Conclusions: The alcohol-based nasal antiseptic was effective in reducing healthcare-onset MRSA bacteremia in this intensive care population. This approach may be a safe and effective alternative to nasal antibiotic ointment that avoids antibiotic resistance risks.Funding: NoneDisclosures: None

Staphylococcal Decolonization to Prevent Surgical Site Infection: Is There a Role in colorectal surgery?

Background: Colorectal surgery is associated with a high risk of surgical site infections (SSIs), with an incidence ranging from 16.9% to 20%, and SSIs are associated with significant morbidity and mortality, prolonged length of hospitalization, and increased health care costs. Staphylococcal decolonization is an attempt to alter the microbiome to prevent staphylococcal and other skin flora from accessing the surgical site, and This practice effectively reduces SSIs in orthopedic, neurologic, and cardiac surgeries. A staphylococcal decolonization protocol was enacted in colorectal surgeries at our institution beginning in October 2016. We compared patient outcomes between patients who did and did not undergo preoperative staphylococcal decolonization. Methods: All patients undergoing nonemergent NHSN-defined colorectal procedures from July 2015 until June 2019 at a tertiary-care medical center were included in this retrospective study. Staphylococcal decolonization was performed using chlorhexidine 2% body wash solution, mupirocin nasal ointment, and chlorhexidine 0.12% oral rinse all twice daily for 5 days prior to surgery. All SSIs were defined by NSHN criteria. The primary outcome was SSI, and secondary outcomes were superficial wound infection (SIP) and organ-space infection (IAB). Predictive variables included decolonization status (yes or no), age, gender, body mass index, procedure duration, American Society of Anesthesiologists (ASA) score, diabetes, smoking, and surgical oncology service. Surgical antimicrobial prophylaxis with cefazolin and metronidazole OR cefoxitin, and chlorhexidine skin preparation were standard throughout the study period. Univariate analysis was performed using a χ2 or t test. Multivariable logistic regression was performed to control for all clinically important variables above. All statistical analyses were done using SAS version 9.4 software (Cary, NC). Results: In total, 1,139 patients underwent nonemergent colorectal surgery from July 2015 to June 2019. There were 74 SSIs: 42 IABs and 32 SIPs. Decolonization was performed in 332 of 1,139 cases (29%). There was no difference in overall SSIs between those decolonized and not decolonized (P = .50). However, SIPs were reduced in the group receiving decolonization: 1.2% (4 of 332) versus 3.5% (28 of 807) (P = .04. When controlling for known SSI risk factors, those not receiving decolonization remained at increased risk of SIPs (OR, 3.79; 95% CI, 1.14–12.61; P = .03. Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.Funding: NoneDisclosures: Michelle Doll reports a research Grant from Molnlycke Healthcare.

Diagnostic Criteria and Treatment of Hereditary Hemorrhagic Telangiectasia

Hereditary hemorrhagic telangiectasia (HHT; Osler-Weber-Rendu syndrome; Morbus Osler) represents a syndrome affecting capillary vessels, leading to arteriovenous shunting. With an average worldwide prevalence of 1:5.000-8.000HHT is considered an orphan disease. Arteriovenous shunts involve predominantly the nasal mucosa, the intestine, lung, liver and central nervous system. Epistaxis is the primary and most bothersome complaint of patients with HHT. A multistage therapeutic concept includes nasal ointment, laser therapy under local anesthesia and surgery under general anesthesia, as well as drug therapies. In addition, screening to determine affection of internal organs is carried out. Lesions that require therapy should be treated in an interdisciplinary setting. Treatment of lesions of the skin, oral and gastrointestinal mucosa and liver is carried out in regard to patients' symptoms, whereas vascular malformations of the lung and brain might need treatment without being symptomatic, due to possible life-threatening complications.

The addition of silver nitrate cautery to antiseptic nasal cream for patients with epistaxis: A systematic review and meta-analysis

ObjectiveTo compare the outcomes of the addition of silver nitrate cautery versus antiseptic cream alone in paediatric patients with recurrent epistaxis. MethodsA systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic information was conducted to identify all Randomised Controlled Trials (RCTs) and non-randomised studies comparing the outcomes of the addition of silver nitrate cautery versus antiseptic cream alone in paediatric patients with recurrent epistaxis. Treatment success and persistence of bleeding were primary outcome measures. Secondary outcome measures included treatment side effects. Fixed effects modelling was used for the analysis. ResultsFour studies enrolling 240 patients were identified. There was no significant difference between silver nitrate cautery group and antiseptic cream alone group in terms of complete resolution (Odds Ratio [OR] = 1.07, P = 0.81), the partial resolution (OR = 1.02, P = 0.96) and persistence of bleeding (OR = 0.91, P = 0.71). For secondary outcomes, antiseptic nasal cream was associated with few side effects such as rash in one case and several complaints of bad smell or taste. ConclusionsThe addition of silver nitrate cautery is not superior to the use of antiseptic cream alone in paediatric patients with recurrent epistaxis as it does not improve treatment success or persistence of bleeding.