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Konrad Adenauer Chancellor of Germany 1949-‐1963
“Only a stupid man doesn’t admit to his mistaken opinions.
A wise man changes his opinion upon recognizing
the facts”*
* not an exact quote – I was young at the Mme
* front Against MISuse of ScienMfic data Bode et al. NEJM 2010, Januray 7th
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Bode et al. NEJM 2010, Januray 7th
¤ Did you ever get a clear explanaMon how this miracle is supposed to work?
¤ Did you ever get a clear explanaMon how this is supposed to work?
¤ Why would you only use it for paMents?
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van Vugt et al. Surg Infect doi.:10.1089/sur.2014.022 van Vugt et al. Surg Infect doi.:10.1089/sur.2014.022
van Vugt et al. Surg Infect doi.:10.1089/sur.2014.022
If nearly half of these professionals are S. aureus carriers – Why wouldn’t we decolonize them, or does anyone actually believe that those masks stop S. aureus from spreading?
Sh… can’t get through the mask
… thus, why wouldn’t you treat this nose?
¤ 11 Dutch centers just started a study to evaluate the effect of decolonizaMon
¤ Some university hospitals only implemented “decolonizaMon” for cardiothoracic surgery!
¤ Many hospitals are not doing it! ¤ Many cannot do PCRs or even the needed cultures
¤ Many can’t spare the extra costs
Science Clinic
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¤ LogisMcal nightmare
¤ When to do the screening cultures ² on admission (too late, PCR must) ² during “in-‐take” okay, but how to deliver the meds
¤ When & how to start the treatment ² At least 3-‐Mmes before the operaMon – aker that by the nurses in the hospital (they will love you for the extra work)
² Start on day 5 before the operaMon – first day in hospital = last day
¤ LogisMcal nightmare
The soluMon: Treat them all !
¤ Far to expensive
The soluMon: Treat them all ! culture € > treatment €
¤ Missing the intermediate carriers
The soluMon: Treat them all !
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Decolonisation – Is it effective?
• Decolonisation – Mupirocin effective for MRSA eradication1 – Reduction in S. aureus infection2,3
(RR 0.55, 95% CI 0.43 - 0.70)2
• Source control - Chlorhexidine – Routine bathing in ICU4,5
• MRSA acquisition decreased by 32%
• HCAI BSI rates decreased by 28%
1. Ammerlaan et al. Clin Infect Dis 2009; 48: 922-30 2. van Rijen et al. Cochrane Database Syst Rev 2008; 4: CD006216 3. Bode et al. N Engl J Med 2010; 362: 9-17 4. Climo MW et al. Crit Care Med 2009; 37:1858-1865 5. Climo MW et al. N Engl J Med 2013; 368: 533-42
Relationship between mupirocin use and resistance
Patel et al. Clin Infect Dis 2009; 49: 935-41
… but not if you give it to 70% of the people who don’t need it !
Mupirocin Resistance in MRSAHUG 1999-2008
0
200
400
600
800
1000
1200
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
No
. iso
late
s (1
iso
late
per
p
atie
nt p
er y
ear)
0
10
20
30
40
50
60
70
80
90
100
% is
ola
tes
resi
stan
t
Sensitive
Resistant
% Resistant
Clinical significance of resistance
• Mupirocin • High-level - decolonization failure1
• Low-level - unclear
• Chlorhexidine • qacA/B gene carriage - unclear2
1. Robicsek et al. Infect Control Hosp Epidemiol 2009; 30: 623-32 2. Vali L et al. J Antimicrob Chemother 2008; 61: 524-32
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Epidemiology of Chlorhexidine Resistance in MRSA
• qacA/B genes found worldwide in MRSA1
– 10%–20% UK – 63% European
– 80% Brazilian – 55% Taiwanese
1. Batra et al. Clin Infect Dis 2010; 50: 210-7
Genotypic chlorhexidine resistance in MRSA blood culturesHUG 1999 to 2008
0
2
4
6
8
10
12
14
16
18
20
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Nu
mb
er
of
MR
SA
blo
od
cu
ltu
re is
ola
tes
qacA-qacB absent
qacA-qacB presentqacA-qacB in 161/188 (86%) blood cultures
Resistance in Blood Cultures HUG 1999 to 2008
No. isolates %
Sensitive 25 13
Resistant
Mupirocin only 2 1
Chlorhexidine only 60 32
Both 101 54
Total 188 100
The Question 2
Is there a correlation between mupirocin use and emergence of
resistance?
Relationship between mupirocin consumption and mupirocin resistance
0102030405060708090
100
80 100 120 140 160 180 200
Mupirocin consumption (g)
Mu
pir
oci
n r
esis
tan
ce (%
)
r = 0.87, p= 0.002
The Question 3
Are low-level mupirocin and chlorhexidine resistance
associated with decolonisation failure ?
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Cases Controls Univariate analysis
Exposure n (%) n (%) OR (95% CI) p value
Mupirocin resistance
L-MuR 49 (64) 26 (35) 3.4 (1.7-7.1) 0.0003
V588F mutation 52 (69) 26/73 (36) 4.6 (2.1-9.9) <0.0001
mupA gene 12/49 (24) 2/26 (8) 5.1 (1.0-25.8) 0.03
Chlorhexidine resistance
qacA/B gene 68 (91) 51 (68) 10.2 (2.6-40.7) <0.0001
Resistance combinations
Fully sensitive 6 (8) 24 (32) 0.1 (0.007-0.37) <0.0001
Mupirocin R only 1 (1) 0 (0) … 0.32
Chlorhexidine R only 21 (28) 25 (33) 0.7 (0.3-1.6) 0.44
Resistant to both 47 (63) 26 (35) 3.2 (1.6-6.5) 0.001
Results - Resistance to Mupirocin and Chlorhexidine Conclusions
1. Mupirocin and chlorhexidine resistance are common in MRSA at HUG (and elsewhere)
2. Resistance correlates with use of these agents
3. Low-level mupirocin and chlorhexidine resistance are strongly associated with failure of decolonization therapy
Conclusions (2)
4. Emergence of resistance and its impact should be monitored in institutions with widespread use of these agents
5. Alternative agents may be required to effectively prevent S. aureus infections in settings with high prevalence of resistance
Steed et al. Am J Infect Control 2014
Steed et al. Am J Infect Control 2014 Steed et al. Am J Infect Control 2014
¤ Very effecMve in reducing the bacterial load, but …
¤ … 2 hours aker last applicaMon: what is the bacterial load on the next morning?
¤ … no informaMon about effect aker mulMple day use (load reducMon?, side effects?)
¤ … no informaMon on the percentage of HCWs that became MRSA-‐free
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Bryce et al. J Hosp Infect 2014; doi: 10.1016/j.jhin.2014.06.017. [Epub ahead of print]
… am I even needed?
Johnson et al. J Arthroplasty 2010;25:Suppl.1
Two wipes, no muprirocin, no infecMon !
… always thought so – not needed!
nasal cover-up* 3 g
* for non-‐compliance with IC measures and paMent miss-‐management
¤ PrevenMng HAI?
¤ Scrub versus wipes ² Significant difference in acMve concentraMon on skin
Noto et al. JAMA. 2015;313(4):369-‐378
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Let’s fight S. aureus. Love to Screen & Scrub.
¤ Are they convinced that decolonizaMon is needed? ² InformaMon only probably doesn’t work à screening & informaMon probably does
¤ What is the compliance with decolonizaMon? ² Unknown à but we sMll see S. aureus infecMons
¤ What are their abiliMes to apply the treatment? ² Can the elderly even use a CHX-‐scrub?
¤ Since this is not the typical elderly paMent
q Nearly impossible logisMcs in hospitals
q Expensive or as an alternaMve (treat them all) leading to resistance
q Frequently not taken-‐up by paMents q Impossible for elderly paMents
q Not the most acMve CHX chosen
q All of the above
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Disclaimer: My personal conclusions on the mauer might be different from the presented content
