Skip to main content
×
Home

Effectiveness of Measures to Eradicate Staphylococcus aureus Carriage in Patients with Community-Associated Skin and Soft-Tissue Infections: A Randomized Trial

  • Stephanie A. Fritz (a1), Bernard C. Camins (a2), Kimberly A. Eisenstein (a1) (a2), Joseph M. Fritz (a2), Emma K. Epplin (a1) (a2), Carey-Ann Burnham (a1) (a3), Jonathan Dukes (a2) and Gregory A. Storch (a1) (a2)...
Abstract
Background.

Despite a paucity of evidence, decolonization measures are prescribed for outpatients with recurrent Staphylococcus aureus skin and soft-tissue infection (SSTI).

Objective.

Compare the effectiveness of 4 regimens for eradicating S. aureus carriage.

Design.

Open-label, randomized controlled trial. Colonization status and recurrent SSTI were ascertained at 1 and 4 months.

Setting.

Barnes-Jewish and St. Louis Children's Hospitals, St. Louis, Missouri, 2007–2009.

Participants.

Three hundred patients with community-onset SSTI and S. aureus colonization in the nares, axilla, or inguinal folds.

Interventions.

Participants were randomized to receive no therapeutic intervention (control subjects) or one of three 5-day regimens: 2% mupirocin ointment applied to the nares twice daily, intranasal mupirocin plus daily 4% chlorhexidine body washes, or intranasal mupirocin plus daily dilute bleach water baths.

Results.

Among 244 participants with 1-month colonization data, modified intention-to-treat analysis revealed S. aureus eradication in 38% of participants in the education only (control) group, 56% of those in the mupirocin group (P = .03 vs controls), 55% of those in the mupirocin and chlorhexidine group (P = .05), and 63% off those in the mupirocin and bleach group (P = .006). Of 229 participants with 4-month colonization data, eradication rates were 48% in the control group, 56% in the mupirocin only group (P = .40 vs controls), 54% in the mupirocin and chlorhexidine group (P = .51), and 71% in the mupirocin and bleach group (P = .02). At 1 and 4 months, recurrent SSTIs were reported by 20% and 36% of participants, respectively.

Conclusions.

An inexpensive regimen of dilute bleach baths, intranasal mupirocin, and hygiene education effectively eradicated S. aureus over a 4-month period. High rates of recurrent SSTI suggest that factors other than endogenous colonization are important determinants of infection.

Trial Registration.

ClinicalTrials.gov identifier: NCT00513799.

Copyright
Corresponding author
660 South Euclid Avenue, Campus Box 8116, St. Louis, MO 63110 (fritz_s@kids.wustl.edu)
References
Hide All
1.Hersh AL, Chambers HF, Maselli JH, Gonzales R. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med 2008;168:15851591.
2.Orscheln RC, Hunstad DA, Fritz SA, et al.Contribution of genetically restricted, methicillin-susceptible strains to the ongoing epidemic of community-acquired Staphylococcus aureus infections. Clin Infect Dis 2009;49:536542.
3.Kaplan SL. Community-acquired methicillin-resistant Staphylococcus aureus infections in children. Semin Pediatr Infect Dis 2006;17:113119.
4.Toshkova K, Annemulier C, Akineden O, Lammler C. The significance of nasal carriage of Staphylococcus aureus as risk factor for human skin infections. FEMS Microbiol Lett 2001;202:1724.
5.Ellis MW, Hospenthal DR, Dooley DP, Gray PJ, Murray CK. Natural history of community-acquired methicillin-resistant Staphylococcus aureus colonization and infection in soldiers. Clin Infect Dis 2004;39:971979.
6.Fritz SA, Epplin EK, Garbutt J, Storch GA. Skin infection in children colonized with community-associated methicillin-resistant Staphylococcus aureus. J Infect 2009;59:394401.
7.Laupland KB, Conly JM. Treatment of Staphylococcus aureus colonization and prophylaxis for infection with topical intranasal mupirocin: an evidence-based review. Clin Infect Dis 2003;37:933938.
8.Perl TM, Cullen JJ, Wenzel RP, et al.Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:18711877.
9.Bode LG, Kluytmans JA, Wertheim HF, et al.Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010;362:917.
10.Wendt C, Schinke S, Wurttemberger M, Oberdorfer K, Bock-Hensley O, von Baum H. Value of whole-body washing with Chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus-, a randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol 2007;28:10361043.
11.Simor AE, Phillips E, McGeer A, et al.Randomized controlled trial of Chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis 2007;44:178185.
12.Kaplan SL, Hulten KG, Gonzalez BE, et al.Three-year surveillance of community-acquired Staphylococcus aureus infections in children. Clin Infect Dis 2005;40:17851791.
13.McCaskill ML, Mason EO Jr, Kaplan SL, Hammerman W, Lam-berth LB, Hulten KG. Increase of the USA300 clone among community-acquired methicillin-susceptible Staphylococcus aureus causing invasive infections. Pediatr Infect Dis J 2007;26:11221127.
14.Diep BA, Gill SR, Chang RF, et al.Complete genome sequence of USA300, an epidemic clone of community-acquired methicillin-resistant Staphylococcus aureus. Lancet 2006;367:731739.
15.Goering RV, McDougal LK, Fosheim GE, Bonnstetter KK, Wolter DJ, Tenover FC. Epidemiologic distribution of the arginine catabolic mobile element among selected methicillin-resistant and methicillin-susceptible Staphylococcus aureus isolates. J Clin Microbiol 2007;45:19811984.
16.DeLeo FR, Diep BA, Otto M. Host defense and pathogenesis in Staphylococcus aureus infections. Infect Dis Clin North Am 2009;23:1734.
17.Creech CB, Beekmann SE, Chen Y, Polgreen PM. Variability among pediatric infectious diseases specialists in the treatment and prevention of methicillin-resistant Staphylococcus aureus skin and soft tissue infections. Pediatr Infect Dis J 2008;27:270272.
18.Liu C, Bayer A, Cosgrove SE, et al.Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis 2011;52:285292.
19.Gorwitz RJ, Jernigan DB, Powers JH, Jernigan JA; Participants in the CDC-Convened Experts' Meeting on Management of MRSA in the Community. Strategies for clinical management of MRSA in the community: summary of an experts' meeting convened by the Centers for Disease Control and Prevention. Atlanta: Center for Disease Control and Prevention, 2006. http://www.cdc.gov/ncidod/dhqp/pdf/ar/CAMRSA_ExpMtgStrategies.pdf. Accessed January 2, 2011.
20.Fritz SA, Krauss MJ, Epplin EK, et al.The natural history of contemporary Staphylococcus aureus nasal colonization in community children. Pediatr Infect Dis J 2011;30:349351.
21.Lautenbach E, Nachamkin I, Hu B, et al.Surveillance cultures for detection of methicillin-resistant Staphylococcus aureus: diagnostic yield of anatomic sites and comparison of provider-and patient-collected samples. Infect Control Hosp Epidemiol 2009;30:380382.
22.Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing; 16th Informational Supplement. Wayne, PA: CLSI, 2006.
23.Fritz SA, Garbutt J, Elward A, Shannon W, Storch GA. Prevalence of and risk factors for community-acquired methicillin-resistant and methicillin-sensitive Staphylococcus aureus colonization in children seen in a practice-based research network. Pediatrics 2008;121:10901098.
24.Hogue JS, Buttke P, Braun LE, Fairchok MP. Mupirocin resistance related to increasing mupirocin use in clinical isolates of methicillin-resistant Staphylococcus aureus in a pediatric population. J Clin Microbiol 2010;48:25992600.
25.Huang JT, Abrams M, Tlougan B, Rademaker A, Palier AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009;123:e808e814.
26.Heggers JP, Sazy JA, Stenberg BD, et al.Bactericidal and wound-healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award. J Burn Care Rehabil 1991;12:420424.
27.Fisher RG, Chain RL, Hair PS, Cunnion KM. Hypochlorite killing of community-associated methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J 2008;27:934935.
28.Palier AS, Mancini AJ. Eczematous eruptions in childhood. In: Palier AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 3rd ed. Philadelphia: Elsevier, 2006.
29.Fritz SA, Hayek G, Mitchell K, Garbutt J, Fraser VJ. Community-associated Staphylococcus aureus colonization in children with S. aureus skin infections and their household members. In: Program and abstracts of the Infectious Diseases Society of America 47th Annual Meeting; October 29-November 1, 2009; Philadelphia. Abstract 802.
30.Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of Chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007;167:20732079.
31.Popovich KJ, Hota B, Hayes R, Weinstein RA, Hayden MK. Effectiveness of routine patient cleansing with Chlorhexidine gluconate for infection prevention in the medical intensive care unit. Infect Control Hosp Epidemiol 2009;30:959963.
32.Ammerlaan HS, Kluytmans JA, Wertheim HF, Nouwen JL, Bon-ten MJ. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis 2009;48:922930.
33.Loeb M, Main C, Walker-Dilks C, Eady A. Antimicrobial drugs for treating methicillin-resistant Staphylococcus aureus colonization. Cochrane Database Syst Rev 2003:CD003340.
34.Yang ES, Tan J, Eells S, Rieg G, Tagudar G, Miller LG. Body site colonization in patients with community-associated methicillin-resistant Staphylococcus aureus and other types of S. aureus skin infections. Clin Microbiol Infect 2010;16:425431.
35.Buehlmann M, Frei R, Fenner L, Dangel M, Fluckiger U, Widmer ARHighly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers. Infect Control Hosp Epidemiol. 2008;29:510516.
36.Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol 1996;17:811813.
37.Upton A, Lang S, Heffernan H. Mupirocin and Staphylococcus aureus: a recent paradigm of emerging antibiotic resistance. J Antimicrob Chemother 2003;51:613617.
38.Miller LG, Quan C, Shay A, et al.A prospective investigation of outcomes after hospital discharge for endemic, community-acquired methicillin-resistant and -susceptible Staphylococcus aureus skin infection. Clin Infect Dis 2007;44:483492.
39.Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann EmergMed 2010;55:401407.
40.Ellis MW, Griffith ME, Dooley DP, et al.Targeted intranasal mupirocin to prevent colonization and infection by community-associated methicillin-resistant Staphylococcus aureus strains in soldiers: a cluster randomized controlled trial. Antimicrob Agents Chemother 2007;51:35913598.
41.Jones TF, Creech CB, Erwin P, Baird SG, Woron AM, Schaffner W. Family outbreaks of invasive community-associated methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis 2006;42:e7678.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 13 *
Loading metrics...

Abstract views

Total abstract views: 416 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 21st November 2017. This data will be updated every 24 hours.