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

Abstract

Background Despite a paucity of evidence, decolonization measures are prescribed for outpatients with recurrent Staphylococcus aureus skin and soft tissue infections (SSTI). Objective Compare the effectiveness of four regimens for eradicating S. aureus carriage. Design Open-label, randomized controlled trial. Colonization status and recurrent SSTI were ascertained at one and four 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 (controls) or perform 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 one-month colonization data, modified intention-to-treat analysis revealed S. aureus eradication in 38% of participants in the education only (control) group; 56% in the mupirocin group (p=0.03 vs. controls); 55% in the mupirocin/chlorhexidine group (p=0.05); and 63% in the mupirocin/bleach group (p=0.006). Of 229 participants with four-month colonization data, eradication rates were 48% in controls; 56% for mupirocin only (p=0.40 vs. controls); 54% for mupirocin/chlorhexidine (p=0.51); and 71% for mupirocin/bleach (p=0.02). At one and four months, respectively, recurrent SSTI was reported by 20% and 36% of participants. Conclusions An inexpensive regimen of dilute bleach baths, intranasal mupirocin, and hygiene education effectively eradicated S. aureus over four months. High rates of recurrent SSTI suggest factors other than endogenous colonization as important determinants of infection.

Decolonization in Prevention of Health Care-Associated Infections

“…A recent trial compared no intervention to one of three 5-day interventions: intranasal mupirocin alone, intranasal mupirocin with daily CHG bathing, or intranasal mupirocin plus daily bathing with dilute bleach (a quarter cup of 6% sodium hypochlorite per tub of water). At 1 month, S. aureus eradication occurred in only 38% of the control group versus 56% with mupirocin alone (P ϭ 0.03), 55% in the mupirocin and CHG group (P ϭ 0.05), and 63% in the mupirocin and bleach group (P Ͻ 0.01) (125). The most recent IDSA guideline on MRSA recommends that children and adults who have recurrent MRSA skin and soft tissue infections should use intranasal mupirocin and bathe with bleach made with one-fourth cup of bleach in a one-quarter tub (approximately 13 gallons), which represents 2.5 l/ml.…”

Mupirocin and Chlorhexidine Resistance in Staphylococcus aureus in Patients with Community-Onset Skin and Soft Tissue Infections

“…Specifically, the topical antimicrobial agents mupirocin and chlorhexidine have been prescribed for decades for patients in intensive care units and those undergoing surgery and dialysis as a means to eradicate S. aureus carriage to reduce the risk of nosocomial infections (2)(3)(4). During the current epidemic of cutaneous abscesses associated with the emergence of community-associated methicillin-resistant S. aureus (CA-MRSA) strains, these decolonization therapies have been extrapolated to outpatients in an effort to prevent recurrent skin infections (5)(6)(7)(8)(9).…”

Translating Atopic Dermatitis Management Guidelines Into Practice for Primary Care Providers

“…8,9,11 In addition, adding a small amount of bleach (sodium hypochlorite; ∼0.5 cups per 40 gallons of water/full bathtub or 1 mL/L) on a twice weekly basis has been shown to reduce AD severity. 39 Daily use of these dilute bleach baths, or comparable sodium hypochlorite-based products while showering or otherwise washing, 40 may be needed as part of maintenance therapy for moderate to severely affected children (although the effect of managing bacterial colonization alone on recurrent infection has not been established 41 ). The technique can be modified for more local soaking or compressing for maintenance of areas that more often show secondary infection or for patients with current infection who cannot tolerate bathing.…”