Deadly infections cut in sickest hospital patients

A major study in hospital intensive care units shows that bathing patients daily with an antimicrobial soap and applying antibiotic ointment in the nose reduced by 44 percent the bloodstream infections caused by dangerous pathogens, including the drug-resistant bacteria MRSA.

The effort to remove potentially harmful bacteria from ICUs also lowered by 37 percent the number of patients who harbored MRSA (methicillin-resistant Staphylococcus aureus) on their bodies. These patients were not sick from the bacteria but were at risk for MRSA infections and spreading the germ to other patients.

The study’s findings are published online May 29 in The New England Journal of Medicine. Researchers at Washington University School of Medicine in St. Louis, the University of California at Irvine, Harvard Pilgrim Health, Hospital Corporation of America and the U.S. Centers for Disease Control and Prevention (CDC) were involved in the study.

Hospitals must be continually on guard to prevent infections that occur in patients during their stays. These infections can spread quickly, and the sickest patients are most at risk. While vigilant hand washing among hospital staff is critical, many infections also occur from bacteria in patients’ noses and on their skin.

The research involved nearly 75,000 patients who were treated at 43 hospitals, all owned by the Hospital Corporation of America. Infectious diseases physician Victoria Fraser, MD, head of Washington University’s Department of Medicine, helped design and oversee the study.

“The results of this study are very important,” said Fraser, also the Adolphus Busch Professor of Medicine. “The risks of acquiring health-care-associated infections and multidrug-resistant organisms among critically ill patients remain a significant challenge. This study demonstrates new and cost-effective methods to protect patients and improve outcomes in ICUs.”

MRSA is resistant to first-line antibiotic treatments
and is a significant cause of illness and sometimes death, especially among
patients receiving medical care. In hospital ICUs, 75 percent of MRSA infections are considered resistant to commonly used antibiotics.

Of the strategies tested for reducing MRSA infections, the one that proved most effective was arguably the simplest and most straightforward. Rather than screening patients in intensive care units for MRSA and isolating or treating only the carriers, all ICU patients were bathed daily using a soap treated with an antiseptic (chlorhexidine), and all received an antibiotic ointment (mupirocin) applied in the nose for five days.

At Barnes-Jewish Hospital, which was not part of the study, all ICU patients already are bathed daily with the chlorhexidine soap. That routine practice was implemented in 2009 after a study by Fraser and her colleagues showed that the antiseptic soap reduced hospital-associated infections by 25 percent among patients in the medical and surgical ICUs at Barnes-Jewish.

Mupirocin ointment is not used routinely in Barnes-Jewish ICUs or in most other hospital ICUs. There are a small number of bacteria that are already resistant to the antibiotic in the ointment and some concerns about whether broad use of mupirocin in ICUs could speed antibiotic resistance.

“Based on the new data, we’ll evaluate whether to incorporate mupirocin into routine use in our ICUs,” said David Warren, MD, medical director for infection prevention at Barnes-Jewish Hospital and Washington University School of Medicine. “If we use the ointment, we will closely monitor for antibiotic resistance.”

In ICUs, antibiotic-resistant bacteria that usually live harmlessly on the body cause many infections. These infections can cause serious complications for patients, increasing the duration of their hospital stays, driving up costs and raising the risk of death. To address the problem, some states have mandated MRSA screening by hospitals, but experts in the field have questioned whether other measures would be more effective.

As part of the study, patients in ICUs were randomly assigned to one of three approaches for reducing MRSA infections. Patients in the first group were screened for MRSA and isolated if they were found to be carrying the bacteria.

Those in the second group were similarly screened and carriers were isolated, but they also were bathed daily with chlorhexidine soap and received nasal mupirocin ointment for five days to help remove MRSA from the body. All ICU patients in the third group, regardless of whether they harbored MRSA on their bodies, received daily chlorhexidine baths and five days of mupirocin.

The third strategy, known as universal decolonization, was the most effective and the easiest to implement; it also eliminates the need for screening ICU patients for MRSA.

“Overall, the results are very encouraging and provocative,” Warren said.
“The results potentially could be applied to many critically ill
patients in ICUs throughout the country to reduce the incidence of
dangerous infections.”_________________________________________________

The research was funded by the Healthcare-Associated Infections Program (HHSA290201000008I) from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, and the Prevention Epicenters Program (1U01 CI000344) from the Centers for Disease Control and Prevention (CDC).

Huang SS, Septimus ES, Kleinman K, Moody J, Hickok J, Avery TR, Lankiewicz J, Gombosev A, Terpstra L, Hartford F, Hayden MK, Jernigan JA, Weinstein RA, Fraser VJ, Haffenreffer K, Cui E, Kaganov RE, Lolans K, Perlin JB, Platt R. Targeted versus universal decolonization to prevent ICU infection. The New England Journal of Medicine. May 29, 2013.

Washington University School of Medicine’s 2,100 employed and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked sixth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.