Estimated Methicillin-Resistant Staphylococcus aureus Decolonization in Intensive Care Units Associated with Single-Application Chlorhexidine Gluconate or Mupirocin

Abstract

Importance: Chlorhexidine gluconate (CHG) and mupirocin are widely used to decolonize patients with methicillin-resistant Staphylococcus aureus (MRSA) and reduce risks associated with infection in hospitalized populations. Quantifying the association of an application of CHG alone or in combination with mupirocin with risk of MRSA infection is important for studies evaluating alternative decolonization strategies or schedules and for identifying whether there is room for improved decolonizing agents. Objective: To estimate the proportion of patients with MRSA decolonized per application of CHG and mupirocin from existing population-level studies. Design, Setting, and Participants: A stochastic mathematical model of an 18-bed intensive care unit (ICU) in an academic medical center operating over 1 year was used to estimate parameters for the proportion of simulated patients with MRSA decolonized per application of CHG and mupirocin. The model was conducted using approximate bayesian computation with data from an existing meta-analysis of studies conducted from February2005 through January 2015. Data were analyzed from January 2018 through November 2019. Exposure: A universal decolonization protocol for colonized patients in the ICU using CHG or CHG and mupirocin in combination was simulated. Main Outcomes and Measures: The proportion of patients with MRSA decolonized per application of CHG and mupirocin was estimated. Results: The estimated proportion of patients with MRSA decolonized per application of CHG was 0.15 (95% credible interval, 0.01-0.42), and the estimated proportion per application of mupirocin in conjunction with CHG was 0.15 (95% credible interval, 0.01-0.54). A lag in colonization detection was associated with decreases in the CHG estimate (0.11; 95% credible interval, 0.01-0.30) and mupirocin estimate (0.10; 95% credible interval, 0.00-0.34), which were sensitive to the value of the modeled contact rate between nurses and patients. A 1% increase in the value of this parameter was associated with a 0.73% increase in the estimated combined outcomes associated with CHG and mupirocin (95% CI: 0.71, 0.75). Gaps longer than 24 hours in the administration of decolonizing agents were associated with a decrease of within-ICUMRSA transmission. Compared with a mean (SD) of 1.23 (0.27) acquisitions per 1000 patient-days in scenarios with no decolonizing bathing, a bathing protocol administering CHG and mupirocin every 120hours was associated with a mean (SD) acquisition rate of 1.03 (0.24) acquisitions per 1000 patientdays, a 16.3% decrease (95% CI, 14.7%-18.0%; P >.001). Conclusions and Relevance: These findingssuggest that there may be room for significant improvement in anti-MRSA disinfectants, including the compounds themselves and their delivery mechanisms. Despite the decolonization estimates found inthis study, these agents are associated with robust outcomes after delays in administration, which may help in alleviating concerns over patient comfort and toxic effects..