New Tack in Preventing Hospital Infections

Germ-Killing Soap-Ointment Treatment for all ICU Patients Shown to Be More Effective Than Isolating Some After Screening

 

By LAURA LANDRO

To prevent deadly infections in intensive-care units, hospitals often screen all patients for the drug-resistant bacteria MRSA, then isolate or treat those found to carry it with germ-killing soap and ointment.

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Tampa Bay Times/Zuma Press

A nurse in Largo, Fla., helps a patient use chlorhexidine wipes, which have been found to protect against MRSA.

But the largest prevention study of its kind has shown it is far more effective to treat every patient in the ICU with the regimen, without any prior testing.
In the study of nearly 75,000 patients at 74 adult ICUs in 43 Hospital Corp. of America HCA -0.73% facilities, the protocol, known as universal decolonization, reduced all bloodstream infections, including those caused by other germs, by 44%, and reduced the incidence of MRSA-positive cultures in the ICU by 37%. Patients were washed with cloths containing antimicrobial soap chlorhexidine and received a nasal antibiotic ointment, mupirocin.
In contrast, there was no significant decrease in infections in a group of patients who were first screened and then isolated if they were found to carry MRSA. And in a third group in which all patients were tested and then isolated and treated with the soap-ointment combination if they tested positive for MRSA, there was only a 22% reduction in infections.
"This will save lives, and sets a new standard for preventing bloodstream infections in the intensive-care unit," says Jonathan Perlin, president, clinical and physician services group and chief medical officer at HCA. HCA is now implementing the protocol in all of its hospital ICUs. The study was published online Wednesday in the New England Journal of Medicine.
MRSA, for methicillin-resistant Staphylococcus aureus, has become resistant to a host of drugs used to treat infection. About 1% to 2% of people carry MRSA on their skin or in their nose, but they have no symptoms or signs of infection. Once they are hospitalized, however, it can enter their bloodstream during invasive procedures or spread to other patients on health workers' hands.
Though health-care-associated infections from MRSA have declined in recent years, thanks to precautions such as hand-washing and infection-prevention programs in hospitals, they still struck 62,500 patients in 2011 and killed more than 9,000.

John Jernigan, director of the Centers for Disease Control and Prevention's Office of Prevention Research and Evaluation and a co-author of the new study, says it fills important gaps in the science of prevention, which has been "murky to date." Most important, he adds, universal decolonization "reduces all bloodstream infections, not just MRSA." The CDC is in the process of determining how the findings of the study might be used in its infection-prevention recommendations. The agency doesn't now recommend screening all ICU patients but does recommend screening and isolation in certain circumstances when the incidence of MRSA in a facility isn't decreasing with more basic infection-control measures.
The cost effectiveness of the different approaches and questions about whether universal decolonization might increase resistance to the germ-killing agents are being investigated in a second phase of the study. HCA's experience is that universal decolonization is less-expensive than the other two approaches, Dr. Perlin says, and the cost of treating hospital infections is of far greater concern.
Several states now require screening all ICU patients for MRSA. But the cultures used to detect MRSA can be costly, and in the time it takes for them to come back from the lab, carriers can infect others or themselves, Dr. Perlin says. Isolating MRSA carriers also is difficult for patients and families.
The study included investigators from Harvard University and other academic institutions, as well as the CDC and the Agency for Healthcare Research and Quality. Carolyn Clancy, director of AHRQ, says because MRSA screening has been adopted by many hospitals, "it may take some time for the medical community to assess the degree to which the study findings should eliminate this practice." The state laws requiring screening also are a complicating factor, Dr. Clancy says, as are questions of cost and resistance.
The study noted that widespread use of chlorhexidine and mupirocin could possibly engender resistance, and the CDC's Dr. Jernigan acknowledges that "any health-care organization that chooses to use this approach will need to be very vigilant." At present, however, there is no strong evidence of resistance, Dr. Perlin says, "and right now we have a real-world concern about infections that can be catastrophic for patients."

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