Prevention of MRSA pneumonia by oral vancomycin decontamination: a randomised trial

Abstract

This study was undertaken to assess whether oropharyngeal vancomycin may control oropharyngeal carriage and lower airway infection due to methicillinresistant Staphylococcus aureus (MRSA) acquired in the intensive care unit (ICU). Secondary endpoints were the emergence of vancomycin-resistant enterococci, vancomycin-intermediate S. aureus and vancomycin consumption.A total of 84 patients, admitted to a medical/surgical ICU and mechanically ventilated for w72 h, were randomly assigned to control (n=42) or test (n=42) group. Both groups received the protocol of selective decontamination of the digestive tract, including polymyxin E, tobramycin and amphotericin B. Patients in the test group received 0.5 g of a 4% vancomycin gel at 6-h intervals in the oropharynx.Lower Aspiration of contaminated oropharyngeal secretions is the main pathway for the development of lower airway infections in patients requiring mechanical ventilation on the intensive care unit (ICU) [1]. Individuals with an underlying disease are often oropharyngeal carriers of abnormal aerobic Gramnegative bacilli (AGNB) [2] and methicillin-resistant Staphylococcus aureus (MRSA) [3]. Prevention and eradication of the abnormal carrier state can be achieved by the administration of nonabsorbable antimicrobials into the oropharynx, as part of selective decontamination of the digestive tract (SDD) [4].The European Task Force on ventilator-associated pneumonia [5] and the Consensus Conference in Critical Care on ICU-acquired pneumonia [6] acknowledged SDD as an evidence-based manoeuvre that reduces both pneumonia and mortality. These recommendations were based on two metaanalyses of randomised controlled trials [7,8]. Recently, two individual trials of huge sample size confirmed the metaanalytic evidence [9,10]. The SDD strategy, using both parenteral and enteral antibiotics, significantly reduced pneumonia and other lower airway infections, combined with 8% absolute mortality reduction. The impact of SDD was similar in medical and surgical patients. Surveillance cultures are recommended to detect emergence of resistance.Three SDD trials included oropharyngeal vancomycin in order to clear MRSA, which is intrinsically resistant to polymyxin and aminoglycosides, from the oropharyngeal cavity [11][12][13]. However, a separate analysis of the impact of topical vancomycin on MRSA lower airway infections was not performed in any of these studies.A randomised trial was conducted to assess the impact of a 4% vancomycin gel, applied into the oropharynx, on MRSA lower airway infections in patients treated on a medical/ surgical ICU. Secondary endpoints were carriage rates and indices of MRSA in the oropharynx, the emergence of vancomycin-resistant enterococci (VRE), as well as vancomycinintermediate S. aureus (VISA) and vancomycin consumption. Material and methods Study subjectsThis study was conducted over a 1-yr period, in an eightbedded ICU, at a multidisciplinary regional-referral hospital. The ICU is a facility with an annual admission rate of y350 pat...

Intestinal carriage of Staphylococcus aureus: how does its frequency compare with that of nasal carriage and what is its clinical impact?

“…More novel treatment modalities for intestinal MRSA elimination to control transmission or subsequent infections, e.g., using oral vancomycin, have been described merely in uncontrolled or observational studies. Oral vancomycin treatment results were reported that showed that the eradication of MRSA intestinal carriage by enteral vancomycin in subsets of adult ICU patients [58][59][60] as well as in pediatric patients [61,62] was effective, but had limited effect on the prevention of transmission. The results from prospective controlled studies of intestinal MRSA decolonization are urgently awaited.…”

Use of selective decontamination of the digestive tract in United Kingdom intensive care units*

“…A recent study from Spain comparing MRSA rates in burns patients receiving SDD without vancomycin for a 5-year period to rates in a subsequent 4-year period when vancomycin was added to the SDD regimen demonstrated a significant reduction in MRSA acquisition in the latter period [19]. Other studies have demonstrated a reduction in MRSA acquisition [20,21] and control of an MRSA outbreak [22] with vancomycin-containing regimens. No significant problems with the emergence of VRE were noted in these studies.…”

Supportive Care of A Critically Ill Child

“…e) Oral Hygiene Oropharyngeal colonization is of significant importance in the pathogenesis of Ventilator associated pneumonia, and a targeted approach to prevent colonization at this site may be an effective method of infection prevention. Several studies have documented benefit of selective oral decontamination in adults [17][18][19]. Surveys performed in the US and UK suggested that oral care methods were not consistent with current research and oral care protocols [20,21].…”