Bacterial Infections in Neonates Following Mupirocin-Based MRSA Decolonization: A Multicenter Cohort Study

Abstract

Objective To characterize the risk of infection after Staphylococcus aureus decolonization with intranasal mupirocin. Design Multicenter, retrospective cohort study. Setting Tertiary care neonatal intensive care units (NICUs) from three urban hospitals in US. Bed size range: 45–100. Methods MRSA-colonized neonates were identified from NICU admissions occurring from January 2007–December 2014, during which a targeted decolonization strategy was used for MRSA control. In two time-to-event analyses, MRSA-colonized neonates were observed from date of first MRSA positive surveillance screen until 1) first occurrence of novel gram-positive cocci in sterile culture or discharge and 2) first occurrence of novel gram-negative bacilli in sterile culture or discharge. Mupirocin exposure was treated as time varying. Results A total of 522 MRSA-colonized neonates were identified from 16,144 neonates admitted to site NICUs. Of the MRSA-colonized neonates, 384 (74%) received mupirocin. Average time from positive culture to mupirocin treatment was 3.5 days (sd=7.2 days). The adjusted hazard of gram-positive cocci infection was 64% less among mupirocin-exposed versus mupirocin-unexposed neonates (HR=0.36, 95% CI: 0.17–0.76), while the adjusted hazard ratio of gram-negative bacilli infection comparing mupirocin-exposed and -unexposed neonates was 1.05 (95% CI: 0.42–2.62). Conclusions In this multi-centered cohort of MRSA-colonized neonates, mupirocin-based decolonization treatment appeared to decrease the risk of infection with select gram-positive organisms, as intended, and was not significantly associated with risk of subsequent infections with organisms not covered by mupirocin’s spectrum of activity.

New Threats from an Old Foe: Methicillin-Resistant <b><i>Staphylococcus aureus</i></b> Infections in Neonates

“…Moreover, the importance of new screening methods, such as polymerase chain reaction and whole-genome sequencing, needs to be defined [6, 7, 10, 16, 64]. Since MRSA resistant to mupirocin and antiseptics have been reported [18, 44, 71], the efficacy of nasal mupirocin application in primary and persistent MRSA decolonization warrants verification [10, 70, 72], Finally, potential adverse effects of antiseptic baths, such as skin irritation and toxicity [73], as well as nonantimicrobial strategies like maternal skin-to-skin contact for MRSA decolonization remain subjects of discussion [74]. …”

Mupirocin for Staphylococcus aureus Decolonization of Infants in Neonatal Intensive Care Units

“…The absence of NEC and non-SA clinical infections in our study and elsewhere is also reassuring. 31 Finally, emergence of mupirocin-resistant strains was uncommon in our population, as it has been in other NICU decolonization programs. 8,33 Resistant strains appeared in enrollment swabs at 1 site, but we cannot determine whether the cause was our intervention or the introduction of a resistant strain from an exogenous source.…”

“…29 Various targeted MRSA decolonization programs for infants in the NICU have been evaluated retrospectively by using historical controls as the comparator. 28,30,31 In some instances, infants who had been recolonized were retreated. Each of these studies revealed a treatment effect; however, the duration of the effect, the impact of retreatment, and the effect of secular changes cannot be fully elucidated when historical controls are used.…”

SHEA neonatal intensive care unit (NICU) white paper series: Practical approaches to Staphylococcus aureus disease prevention

“…Data showing efficacy and safety of S. aureus decolonization to reduce infection risk are primarily available from observational studies and a recent randomized trial that was not powered to detect a reduction in S. aureus infections. 6,29,30,[35][36][37] Even though decolonization has included treatment with topical antibiotics, topical antiseptics, and rarely, systemic antimicrobials, intranasal mupirocin alone is most commonly used. Intranasal mupirocin is not approved by the US Food and Drug Administration (FDA) for this indication in neonates, yet numerous studies reporting the use of mupirocin for S. aureus decolonization have not identified any clinically relevant adverse effects.…”

“…Small retrospective studies have suggested that undetected MRSA carriers that are not placed on contact precautions pose a significant risk to other patients within the unit. 36 However, if healthcare personnel perceive admitted neonates to be at low risk of MRSA colonization, then preemptive contact precautions are likely not indicated. Some states mandate screening all neonates, even those at low risk of colonization.…”