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Decolonization Therapy

Decolonization Therapy. The Pros and Cons Elizabeth Bryce, MD Bruce Gamage, RN. Overview. Literature review for decolonization therapy: pros and cons Decision Tree as to whether to decolonize Key components in the decolonization process. Literature Review. Main References:

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Decolonization Therapy

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  1. Decolonization Therapy The Pros and Cons Elizabeth Bryce, MD Bruce Gamage, RN

  2. Overview • Literature review for decolonization therapy: pros and cons • Decision Tree as to whether to decolonize • Key components in the decolonization process

  3. Literature Review Main References: • PICNet Draft ARO Guidelines • Management of multidrug-resistant organisms in healthcare settings, 2006 Siegel et al AJIC 2007:35:S165-193 • Guidelines for the control and prevention of MRSA in Healthcare Facilities by the Joint BSAC/HIS/ICNA Working Party of MRSA J Hosp Infection 2006;63:S1-S44

  4. Decolonization Background • Use of topical and/or systemic agents to eradicate/reduce MRSA carriage on skin and mucus membranes • Purpose is to reduce risk of transmission in healthcare settings • Efficacy dependent on multiple factors related to the patient e.g.health status, wounds, foreign bodies, feeding tubes, compliance

  5. Is it effective? Possibly in certain circumstances…. Healthcare workers • Colonized or infected HCWs with epi links to outbreaks or cluster events (e.g. SSIs) Patients • As above • Prior to certain surgical procedures to reduce SSI risk

  6. What regimens work? • Topical mupirocin alone associated with significant relapse or reinfection rate • Higher success with mupirocin, CHG baths, systemic therapy but again recolonization occurs • Unable to evaluate the success of one intervention alone in these studies • Intact skin and underlying good health very important determinants of “success”

  7. Community MRSA Consider if: • Recurrent skin infections( > two in 6 mos) and no evidence of repeated reexposure OR • As a PH strategy to decrease transmission

  8. Real Life • Most reviews do not support intranasal mupirocin alone UNLESS short term use for patients about to undergo major surgery (e.g. cardiac, ortho) OR conventional methods have failed to control an outbreak (e.g. NICU) • Multiple agent intervention more successful and generally used for very selected patient populations or HCWs (e.g. surgeons). Generally use combinations of mupirocin, CHG, and if susceptible combos of clindamycin or SXTor rifampin

  9. What This Means • Never been proven that any group of patients or HCWs remain permanently MRSA free • Confounded by reacquisition of MRSA from patients or other HCWs • Increasing prevalence of community acquired MRSA poses a new dimension

  10. MRSA Identified MRSA Infection MRSA Colonization MRSA infection treated according to antibiotic susceptibility and clinical presentation Routine decolonization is not recommended • Possible consideration for decolonization: • Outbreak situation • Recurrence of infection following treatment • Preoperatively Consultation to ID specialist or other medical expert. If patient is under 17 years consult paediatric ID specialist • Decolonization may not be effective* if there are: • Open Wounds • Invasive devices • Intravenous lines • Urinary catheters • Feeding tubes • Tracheostomies • *Persistence of carriage in 40% of patients MRSA Decolonization Decision Algorithm

  11. If an MRSA positive case is assessed by an ID/IC expert and decolonization is advised, obtain patient specific decolonization orders from physician If patient is under 17 consult a paediatric ID specialist Once decision to decolonize has been made, decolonization protocols consider ALL of these steps Topical Therapy: Mupirocin cream to nares is recommended Systemic Therapy: Ideally two oral antibiotics should be chosen for systemic therapy, based on susceptibility testing, one of which should be Rifampin if possible After daily bath and shampoo with chlorhexidine gluconate, daily change of clothing and bed linen Remove and replace urine catheter as necessary during course of therapy Consult pharmacy for additional recommendations regarding dosage, drug interaction and monitoring. Consider monitoring liver function for individuals with impaired hepatic function. Dosage may be modified in individuals with impaired renal/hepatic function Replace other foreign bodies (e.g. gastrostomy tube) if possible POST DECOLONIZATION Maintain Contact Precautions until at least 2 consecutive negative specimens obtained 1 week apart. The culture should be taken no less than 48 hours after decolonization treatment has ceased and the second no leas than 7 days after the first. MRSA Decolonization Process Algorithm

  12. Summary • Decolonization not routine • Valuable in some circumstances • Success is variable • Follow decision/decolonization algorithm

  13. Questions?

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