A "con" presentation of something I am really very much "pro". Still, this were the barriers I had to overcome why implementing S. aureus decolonization

1. 30-­‐04-­‐15
1
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

2. 30-­‐04-­‐15
2
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?

3. 30-­‐04-­‐15
3
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

4. 30-­‐04-­‐15
4
¤
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
!

5. 30-­‐04-­‐15
5
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 MRSA
HUG 1999-2008
0
200
400
600
800
1000
1200
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
No.isolates(1isolateper
patientperyear)
0
10
20
30
40
50
60
70
80
90
100
%isolatesresistant
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

6. 30-­‐04-­‐15
6
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 cultures
HUG 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
NumberofMRSA
bloodcultureisolates
qacA-qacB absent
qacA-qacB present
qacA-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
0
10
20
30
40
50
60
70
80
90
100
80 100 120 140 160 180 200
Mupirocin consumption (g)
Mupirocinresistance(%)
r = 0.87, p= 0.002
The Question 3
Are low-level mupirocin and
chlorhexidine resistance
associated with
decolonisation failure ?

7. 30-­‐04-­‐15
7
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

8. 30-­‐04-­‐15
8
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

9. 30-­‐04-­‐15
9
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

10. 30-­‐04-­‐15
10
Disclaimer:
My
personal
conclusions
on
the
mauer
might
be
different
from
the
presented
content