May 29, 2013 (CIDRAP News) – Disinfecting all intensive care unit (ICU) patients was found to be more effective and easier to implement than specifically screening ICU patients for methicillin-resistant Staphylococcus aureus (MRSA) before disinfection in a study of more than 70,000 patients published today.
The more sweeping germ-killing approach—a process called decolonization—reduced bloodstream infections by up to 44% and significantly reduced the incidence of MRSA, the study in The New England Journal Medicine (NEJM) found.
The REDUCE MRSA trial was conducted in two stages from 2009 to 2011 by researchers from the University of California, Irvine (UCI), Harvard Pilgrim Health Care Institute, Hospital Corporation of America, and the US Centers for Disease Control and Prevention (CDC).
At issue was whether so-called vertical intervention measures, which focus on reducing colonization and infection with a single pathogen and are typically more expensive, are superior to horizontal interventions, which address all potential pathogens.
Researchers evaluated three MRSA prevention practices:
- Active detection and isolation of MRSA patients—a vertical intervention (group 1)
- Targeted decolonization, with active detection and isolation plus intranasal mupirocin and chlorhexidine bathing for 5 days—a combined intervention (group 2)
- No detection and isolation but universal decolonization with intranasal mupirocin for 5 days and chlorhexidine bathing for the entire ICU stay—a mostly horizontal approach (group 3)
The study included 43 US hospitals, 74 adult ICUs, and 74,256 patients, making it the largest published study on this topic, the CDC said in a news release today.
Researchers found hazards ratios for MRSA clinical isolates of 0.92 for group 1, 0.75 for group 2, and 0.63 for group 3. For bloodstream infections of any type, hazards ratios were 0.99, 0.78, and 0.56, respectively. This translates to a reduction in bloodstream infections of up to 44%.
"This study helps answer a long-standing debate in the medical field about whether we should tailor our efforts to prevent infection to specific pathogens, such as MRSA, or whether we should identify a high-risk patient group and give them all special treatment to prevent infection," lead author Susan Huang, MD, MPH, of UCI said in the CDC release. "The universal decolonization strategy was the most effective and the easiest to implement. It eliminates the need for screening ICU patients for MRSA."
CDC Director Thomas Frieden, MD, MPH, said in the release, "CDC is working to determine how the findings should inform CDC infection prevention recommendations."
In an accompanying NEJM editorial today, infectious disease experts Michael B. Edmond, MD, MPH, and Richard P. Wenzel, MD, of Virginia Commonwealth University said the strengths of the study "include its large size and rigorous design. Weaknesses include a lack of surveillance for infections other than bloodstream infections and a failure to assess for resistance to chlorhexidine or mupirocin."
But Edmond and Wenzel called the implications of the study "highly important."
They added that the findings have ramifications beyond MRSA. "The recent dissemination of carbapenem-resistant Enterobacteriaceae has stimulated calls to implement active detection and isolation for these organisms," they wrote. "We hope that the results of this study will redirect that discussion and reinforce the utility of horizontal interventions to control not only the pathogens of today but those of tomorrow as well."
The study was funded by the Department of Health and Human Services.
Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013 (published online May 29) [Full text]
Edmond MB, Wenzel MP. Screening inpatients for MRSA—case closed. (Editorial) N Engl J Med 2013 (published online May 29) [Full text]
See also:
May 29 CDC press release
