Running head: DECREASING METHICILLIN-RESISTANT

Decreasing Methicillin-Resistant Staphlococcus aureus Infection Rates with Universal Chlorhexidine Bathing Practices Kimberly Cremerius University of South Florida

DECREASING METHICILLIN-RESISTANT Abstract

This paper focuses on four articles intending to support the implementation of universal, daily chlorhexidine baths for all patients in the hospital setting instead of targeted screening and decolonization practices that the hospital currently practices to decrease the incidence of infection from Methicillin-resistant Staphylococcus areus (MRSA). All the articles are from PubMed database and found using key words such as MRSA, chlorhexidine baths, infection control, and prevention. The results of the trials presented in the articles reinforce the practice of chlorhexidine bathing practices to decrease the MRSA infection rates. The evidence from the four articles buttresses a claim to change the current practices at Florida Hospital of Tampa and implement instead the universal decolonization practice of daily chlorhexidine baths for all patients admitted to the hospital.

DECREASING METHICILLIN-RESISTANT Synthesis Paper Formative Methicillin-resistant Staphlococcus aureus (MRSA) is a type of bacteria that does not respond to antibiotics that physicians use to treat most staph infections (Mayo Clinic, 2013). According to the Centers for Disease Control and Prevention (2013), although the incidence of

hospital associated MRSA infections has decreased significantly in the last several years MRSA continues to be one of the leading causes of hospital associated infections. The estimated number of overall MRSA infections out of a population of 100,000 people is 80,461cases. The medical community still encourages improvement in the prevention and treatment of MRSA to continue decreasing the incidence rates in the hospital setting (Centers for Disease Control and Prevention [CDC], 2013). The aim, based on the review of the literature, is to support the practice of universal decolonization with chlorhexidine baths compared to targeted screening and decolonization to decrease the spread of nosocomial MRSA infections throughout patients time in the hospital. Literature Search The articles included in this synthesis were found using PubMed database. The key words used to search for the articles included MRSA, chlorhexidine baths, infection control, and prevention. Literature Review In Huang et al.s (2013) randomized control trial, they studied three groups to analyze the effects of different isolation practices on the three differing groups of patients in the ICU. The first group (n = 23,480) consisted of screening and isolation which included testing the patients in the group for MRSA and enacting the use of contact precautions for patients with a history of MRSA colonization or received a positive MRSA test result. The second group (n = 22,105)

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studied targeted decolonization, which incorporated the same screening and isolation practices as the first group. The targeted decolonization group furthered the intervention for MRSA by initiating decolonization treatment for five days for patients that had a previous history of MRSA colonization or had positive MRSA test results. The decolonization treatment consisted of the application of intranasal mupirocin twice a day for five days in addition to using chlorhexidineimpregnated cloths for the daily bath throughout the patients stays in the ICU. The third group (n = 26,024) tested universal decolonization where no screening took place. All patients received the intranasal mupirocin treatment for five days with the daily baths using chlorhexidineimpregnated cloths throughout their stay in the ICU. The primary outcome measured included MRSA positive clinical cultures that occurred during the patients stays in the ICU. The secondary outcomes consisted of MRSA or any other pathogen associated infections in the bloodstream that the patients obtained from the ICU. The trial participation population consisted of the patients from 43 hospitals, which included 74 ICUs. The results of the primary outcome concluded that universal decolonization group had notably decreased amount of MRSA-positive blood cultures compared to the screening and isolation group (P= 0.01). The results of the secondary outcome concerning MRSA bloodstream infections did not significantly differ between the groups (P= 0.11). The secondary outcome concerning any pathogen bloodstream infections, however, did support universal decolonization. The third group had a reduced incidence of infection compared to the screening and isolation (P< 0.001) group and the targeted decolonization group (P= 0.04). This is a double blinded, randomized control trial with an appropriate control group and valid and clinically important outcomes. Although this study ascertained clinically significant results, it does not demonstrate if both the mupirocin and the

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chlorhexidine baths are necessary, or if either one is sufficient for decreasing the rate of infection (Huang et al., 2013). In the study enacted by Kassakian, Mermel, Jefferson, Parenteau, and Machan (2011), the purpose was to investigate the use of 2% chlorhexidine-impregnated cloths against soap and water baths. The primary outcome measured consisted of the incidence rate of MRSA and vancomycin-resistant enterococci (VRE) hospital associated infections. The secondary outcome measured was Clostiriduium difficile hospital associated infection. The researchers included the secondary outcome as a dependent variable not related to the primary outcome measures. In the control group (n = 7,699), the nurses washed the patients with soap and water from January 1 through December 31, 2008. In the intervention group (n = 7,102), the nurses implemented baths with clorhexidine gluconate (CHG)-impregnated cloths once a day from February 1 through March 31, 2009. The results of this study showed that the rate of hospital associated infection with MRSA and VRE in the intervention group was 64 percent less than the control group (P= 0.06). The results did not show a significant effect on the rates of C. difficile (P = 0.6). This trial was not randomly controlled and the control group data collection took place before the intervention group. However, the results were significantly different to support the use of 2% chlorhexidine-impregnated cloths (Kassakian et al., 2011). In Harbarth et al.s (2008) study, the researchers tested the effect of rapid screening and infection control on patients before surgery to determine if it decreased the incidence of nosocomial MRSA infection compared to infection control alone with no screening process. Participants of the trial were patients that arrived to 12 different surgical wards with eight different specialties. There were two intervention periods throughout the study. In the first intervention period, the researchers collected data on the patients in five of the eight specialties,

DECREASING METHICILLIN-RESISTANT the other three being the control. In the second intervention period the groups switched. The studied population included 21,754 patients on the surgical wards. The data revealed that there was no significant decrease in the amount of nosocomial MRSA infections in the intervention

group compared to the control group (P = 0.29). The rapid screening did not have a great enough impact to suggest that hospitals should now implement rapid screening into common practice. Although this trial was not randomly controlled, it performed a crossover design, which decreased the amount of variables that could not be measured and that could have interfered with the results of the study (Harbarth et al., 2008). In this final study, Robicsek, Neaumont, Thomson, Govindarajan, and Peterson (2009) collected data on decolonization where participants were split into four different groups with differing number of treatments of nasal mupirocin, either 0, 1-3, 4-7, or 8 or more treatments. There were two studies performed with the collected data. The first study reviewed how the decolonization treatments affected the possibility of the colonization persisting. The second study focused on how the treatments affected the risk of infection from the colonized MRSA. The researchers chose the sample population based on the patients who were admitted to the hospital and had positive colonization MRSA test results. There were 407 patients who participated in the study. The results indicated that the mupirocin treatments of any amount eliminated the colonization of MRSA (P = 0.076). However, the decolonization process did not protect against future colonization. The second studys results showed that the mupirocin treatments postponed patient infection, but did not decrease the risk of becoming infected. These studies were not randomized and a larger population may have yielded different results (Robicsek et al., 2009). The study does not provide evidence that supports the use of nasal

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mupirocin to decrease the rates of MRSA infection, and therefore eliminates the need to include this treatment with chlorhexidine baths. Synthesis The articles summarized above provide evidence to support chlorhexidine baths in different ways. Huang et al.s (2013) trial reinforces the application of chlorhexidine baths to all patients in the hospital, not just the patients who receive positive MRSA tests. Implementing the chlorhexidine baths significantly decreased the rate of MRSA infection (P = 0.01) (Huang et al., 2013). Kassakian et al.s (2011) study supports the findings in Huang et al.s trial by confirming the decreased rate of MRSA infection (P = 0.06) when implementing baths with 2% chlorhexidine-impregnated cloths instead of soap and water baths. According to the evidence, implementing chlorhexidine baths to all units of the hospital will decrease the rates of MRSA infection, not just in ICU or critical care sections, but throughout the hospital. Harbarths et al.s (2008) trial disproves the necessity of rapid testing to decrease the rate of MRSA infection, which suggests that screening patients before implementing the chlorhexidine baths would not affect the infection rate when every patient receives the bath despite a positive or negative test result. The final article nullifies the necessity for universal application of mupirocin, which Huang et al. (2013) also tested alongside the chlorhexidine baths, because it does not significantly decrease the incidence of infection even though it decolonizes the patient (Robicsek et al., 2009). Clinical Recommendations Currently at Florida Hospital of Tampa, the nurse swabs every patient for MRSA upon admission. If the results are positive, then the patient is put on contact precautions. In the ICU, the nurses give chlorhexidine baths once a day during the patients stay in the ICU. However, on

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the general floors every patient receives a soap and water bath once a day. Based on the evidence chlorhexidine baths decrease the rate of hospital associated MRSA infections. Current practices should change to coincide with the evidence-based research and implement daily chlorhexidine baths for all patients regardless of screening results to prevent the spread of MRSA in the hospital.

DECREASING METHICILLIN-RESISTANT Table 1 Literature Review

Reference McCain, GC, et al (2012). Transition from gavage to nipple feeding for preterm infants with bronchopulumonary dysplasia. Nursing Research, 61 (6): 360397. Aims To test the hypothesis that preterm infants with BPD who transitioned from gavage to nipple feeding in the semi-demand method would achieve nipple feeding sooner and be discharged from the hospital sooner than control infants who received standard care. To test the effect of rapid screening and infection control on patients before surgery to determine if it decreased the incidence of nosocomial MRSA infection compared to infection control alone with no screening process. Design and Measures RCT Measures: -Days to full nipple feedings -LOS Sample 86 preterm infants < 34 weeks gestation; matched for birth weight, gestational age, gender, & race Outcomes / statistics Experimental infants achieved full nipple feeds sooner than control infants (p< .0001); LOS was 5 days shorter in experimental infants, but was not statistically significant.

Harbarth, S., Fankhauser, C., Schrenzel, J., Christenson, J., Gervaz, P., Bandiera-Clerc, C., Pittet, D. (2008). Universal screening for methicillinresistant staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. The Journal of the American Medical Association, 299(10). doi: 10.1001/jama.299.10.1149

Interventional cohort design with crossover design Measures: - Overall rate of nosocomial MRSA infection per 1000 patient-days - Rate of surgical site infection per 100 procedures -Nosocomial MRSA acquisition rate - RCT Measures: - MRSA positive clinical cultures during hospital stay - MRSA bloodstream infection - Any other pathogen associated bloodstream

21,754 surgical patients in the study, all patients that were admitted for more than 24 hours

No significant decrease in the amount of nosocomial MRSA infections in the intervention group compared to the control group (P = 0.29)

Huang, S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T., Platt, R. (2013). Targeted versus universal decolonization to prevent icu infection. The New England Journal of Medicine, 368(24). doi: 10.1056/NEJMoa1207290

To analyze the effects of different isolation (screening and isolation, targeted decolonization, and universal decolonization) practices on three differing groups of patients in the ICU.

Patients from 43 hospitals in the 74 ICUs between the hospitals

Universal decolonization group had notably decreased amount of MRSApositive blood cultures compared to the screening and isolation group (P = 0.01), no significant difference between groups concerning MRSA blood stream infections (P= 0.11). Universal

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infection

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decolonization had decreased amounts of pathogen bloodstream infections. The rate of hospital associated infection with MRSA and VRE in the intervention group was 64 percent less than the control group (P= 0.06). No significant difference in rates of C. difficile (P = 0.6)

Kassakian, S. Z., Mermel, L. A., Jefferson, J. A., Parenteau, S. L., & Machan, J. T. (2011). Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients. Infection Control and Hospital Epidemiology, 32(3). doi: 10.1086/658334

To investigate the use of 2% chlorhexidineimpregnated cloths against soap and water baths to decrease the incidence of MRSA and VRE hospital associated infections.

Quasiexperimental design Measures: -Incidence rate of MRSA and (VRE) hospital associated infect -Clostiriduium difficile hospital associated infection

Robicsek, A., Beaumont, J. L., Thomson, R. B. Jr., Govindarajan, G., & Peterson, L. R. (2009). Topical therapy for methicillin-resistant staphylococcus aureus colonization: Impact on infection risk. Infection Control and Hospital Epidemiology, 30(7). doi: 10.1086/597550

To assess the affect of different number of treatments of mupirocin on the decolonization and infection rate of MRSA

Retrospective cohort study Measures: - Possibility of colonization persisting - Risk of infection from colonized MRSA

7,102 patients in the control group and 7,699 patients in intervention group; participants were the patients admitted in the time frames of the intervention and control groups. 407 patients admitted found to be MRSA carriers and were readmitted during intervention period

mupirocin treatments of any amount eliminated the colonization of MRSA (P= 0.076), but did not protect against future colonization

DECREASING METHICILLIN-RESISTANT References

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Centers for Disease Control and Prevention. (2013). Methicillin-resistant staphylococcus aureus (mrsa) infections. Retrieved from http://www.cdc.gov/mrsa/tracking/index.html Harbarth, S., Fankhauser, C., Schrenzel, J., Christenson, J., Gervaz, P., Bandiera-Clerc, C., Pittet, D. (2008). Universal screening for methicillin-resistant staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. The Journal of the American Medical Association, 299(10). doi: 10.1001/jama.299.10.1149 Huang, S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T., Platt, R. (2013). Targeted versus universal decolonization to prevent icu infection. The New England Journal of Medicine, 368(24). doi: 10.1056/NEJMoa1207290 Kassakian, S. Z., Mermel, L. A., Jefferson, J. A., Parenteau, S. L., & Machan, J. T. (2011). Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients. Infection Control and Hospital Epidemiology, 32(3). doi: 10.1086/658334 Mayo Clinic. (2013). MRSA infection. Retrieved from http://www.mayoclinic.org/mrsa/index.html Robicsek, A., Beaumont, J. L., Thomson, R. B. Jr., Govindarajan, G., & Peterson, L. R. (2009). Topical therapy for methicillin-resistant staphylococcus aureus colonization: Impact on infection risk. Infection Control and Hospital Epidemiology, 30(7). doi: 10.1086/597550