Transcript Decolonization Therapy. The Pros and Cons

Decolonization
Therapy
The Pros and Cons
Elizabeth Bryce, MD
Bruce Gamage, RN
Overview
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Literature review for decolonization
therapy: pros and cons
Decision Tree as to whether to
decolonize
Key components in the
decolonization process
Literature Review
Main References:
 PICNet Draft ARO Guidelines
 Management of multidrug-resistant organisms in
healthcare settings, 2006 Siegel et al AJIC
2007:35:S165-193
 Guidelines for the control and prevention of
MRSA in Healthcare Facilities by the Joint
BSAC/HIS/ICNA Working Party of MRSA J
Hosp Infection 2006;63:S1-S44
Decolonization
Background
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Use of topical and/or systemic
agents to eradicate/reduce MRSA
carriage on skin and mucus
membranes
Purpose is to reduce risk of
transmission in healthcare settings
Efficacy dependent on multiple
factors related to the patient
e.g.health status, wounds, foreign
bodies, feeding tubes, compliance
Is it effective?
Possibly in certain circumstances….
Healthcare workers
 Colonized or infected HCWs with
epi links to outbreaks or cluster
events (e.g. SSIs)
Patients
 As above
 Prior to certain surgical procedures
to reduce SSI risk
What regimens work?
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Topical mupirocin alone associated with
significant relapse or reinfection rate
Higher success with mupirocin, CHG
baths, systemic therapy but again
recolonization occurs
Unable to evaluate the success of one
intervention alone in these studies
Intact skin and underlying good health
very important determinants of “success”
Community MRSA
Consider if:
 Recurrent skin infections( > two in 6
mos) and no evidence of repeated
reexposure OR
 As a PH strategy to decrease
transmission
Real Life
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Most reviews do not support intranasal mupirocin
alone UNLESS short term use for patients about to
undergo major surgery (e.g. cardiac, ortho)
OR conventional methods have failed to control an
outbreak (e.g. NICU)
Multiple agent intervention more successful and
generally used for very selected patient populations or
HCWs (e.g. surgeons). Generally use combinations of
mupirocin, CHG, and if susceptible combos of
clindamycin or SXTor rifampin
What This Means
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Never been proven that any group
of patients or HCWs remain
permanently MRSA free
Confounded by reacquisition of
MRSA from patients or other
HCWs
Increasing prevalence of
community acquired MRSA poses
a new dimension
MRSA Decolonization Decision Algorithm
MRSA
Identified
MRSA
Infection
MRSA infection
treated
according to
antibiotic
susceptibility
and clinical
presentation
MRSA
Colonization
Routine
decolonization
is not
recommended
Possible consideration for
decolonization:
•Outbreak situation
•Recurrence of infection
following treatment
•Preoperatively
Consultation to ID specialist or other medical expert.
If patient is under 17 years consult paediatric ID specialist
Decolonization may not be effective* if there are:
•Open Wounds
•Invasive devices
•Intravenous lines
•Urinary catheters
•Feeding tubes
•Tracheostomies
*Persistence of carriage in 40% of patients
MRSA Decolonization Process
Algorithm
If an MRSA positive case is assessed by an ID/IC expert and decolonization
is advised, obtain patient specific decolonization orders from physician
If patient is under 17 consult a paediatric ID specialist
Once decision to decolonize has been made,
decolonization protocols consider ALL of these steps
Topical Therapy:
Mupirocin cream to
nares is recommended
Systemic Therapy:
Ideally two oral antibiotics
should be chosen for
systemic therapy, based on
susceptibility testing, one
of which should be
Rifampin if possible
Consult pharmacy for additional
recommendations regarding dosage,
drug interaction and monitoring.
Consider monitoring liver function
for individuals with impaired hepatic
function.
Dosage may be modified in
individuals with impaired
renal/hepatic function
After daily bath and
shampoo with
chlorhexidine
gluconate, daily
change of clothing
and bed linen
Remove and replace
urine catheter as
necessary during
course of therapy
Replace other foreign
bodies (e.g.
gastrostomy tube) if
possible
POST DECOLONIZATION
Maintain Contact Precautions until at least 2 consecutive negative specimens obtained
1 week apart. The culture should be taken no less than 48 hours after decolonization
treatment has ceased and the second no leas than 7 days after the first.
Summary
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Decolonization not routine
Valuable in some circumstances
Success is variable
Follow decision/decolonization
algorithm
Questions?