Caveats and cautions of landmark ICU study
Mupirocin resistance top concern
Preventing bloodstream infections — among the most costly and potentially fatal patient complications — provides a benefit so powerful that one is tempted to dismiss the risk. However, there were some caveats and cautions sounded amid a recent announcement that a combination of daily chlorhexidine baths and a five-day regimen of nasal mupirocin ointment nearly halved BSIs due to all causes in adult ICU patients.
"We caution people that we have to be on the lookout for any unexpected or collateral damage. For instance over time, will we see more resistance?" says Edward Septimus, MD, medical director of infection control and epidemiology for the Hospital Corporation of America. "We know there can be low levels of resistance to the ointment, though it's very rare to get resistance to the chlorhexidine. But these are things that have to be carefully monitored as more facilities begin to implement this intervention."
Past research on the issue suggest mupirocin resistance may be kept at bay under limited use protocols, but can increase rapidly if use for patients and/or health care workers becomes indiscriminate. "In particular, resistance seems to emerge readily in health care facilities with unrestricted policies that allow widespread mupirocin use for prolonged periods, especially when application to decubitus ulcers and other skin lesions is allowed," researchers found in a review article on the issue.1
"We didn't directly analyze this question [of resistance] for the abstract," says Susan Huang, MD, MPH, FIDSA, medical director of epidemiology and infection prevention at University of California Irvine Healthcare. "I think that the value in the hybrid study is that if we can prevent infection there is probably some tolerability of some level of resistance. We don't know what that might be and we are going to have to be very careful to look at it. We do have some strains collected from the trial that we will be evaluating carefully, but more importantly as this moves towards wider spread adoption as a nation we'll have to be very vigilant."
While limiting ICU patients to a single five-day regimen may well fall within a safe-use definition of mupirocin, that still means that hospitals that adopt the protocol will have to comply with those parameters. In that same vein, there are some implementation steps which are important in adopting the protocol, which has not been published in any detail. "[That includes] applying the baths correctly and then not using things that might negate the activity of the antibiotic solution," Septimus says. "There are things you have to have in place, but providing you have them in place and use a similar protocol we are hopeful you will get the same results."
AHRQ will eventually post toolkit
Plans call for eventually creating a toolkit to ease implementation for other hospitals. If all goes as planned, the toolkit will be posted on the website of the Agency for Healthcare Research and Quality (AHRQ), which supported the research. "We want to share the implementation steps so everyone can benefit from the results of the study," Huang says.
In terms of adverse topical reactions to the chlorhexidine, Huang says there were 'very few, mainly related to skin rash. It was far below the expected number. All of our rashes disappeared very rapidly on discontinuation of the product."
While the study was targeted particularly at MRSA, infections due to other pathogens generally fell as well. That said, the true benefit of the protocol against infections of other etiologies warrants further analysis, she adds.
"We have to be careful — you can't put a statistical amount on it, but what you see is that the number [of infections] comes down," she says. "It appeared in the descriptive analysis that they are all headed in the right direction, but we did not specifically test in [specific pathogen groups]. We weren't powered to look for that, but it is promising from what we see with the 'eyeball test.'"
In addition, a detailed cost benefit analysis is still being conducted, as the various cost savings of, for example, dropping MRSA screening and isolation measures must be weighed against the purchase and application of the chlorhexidine and ointment. The study was based in adult ICUs, so more research is planned to see if the findings have implications for other hospital patient groups.
"In the non-ICU setting we really don't know very much," she says. "There are anecdotes of people using these types of bathing techniques outside of the intensive care unit. We're really pleased to have a clinical trial that was recently funded that will actually test this [intervention] in the non-ICU settings as well."
Reference
- Patel JB, Gorwitz RJ, Jernigan JA. Mupirocin Resistance. Clinical Infect Dis 2009;49:935-941
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