DECONTAMINATION
the transmission of COVID-19 in healthcare settings during the recent pandemic. Staphylococcus aureus accounts for more HCAIs than any other pathogen. It is the most common cause of ventilator-associated pneumonia and surgical site infection and the second most common cause of central- catheter–associated bloodstream infection.10 Despite the recent decline in incidence of MRSA, infection remains a major cause of avoidable morbidity and mortality in patients admitted to hospital, particularly those in ICU. Many of its most serious clinical manifestations, such as bloodstream infection and ventilator-associated pneumonia, are seen in ICU.11 MRSA infection increases the risk of death, increases the length of hospital stay, and increases treatment costs.12
Patients
may become colonised with MRSA but remain asymptomatic. Such colonisation increases the risk of developing a clinical MRSA infection and is a source of cross infection.12
Colonisation is a proven risk
factor for developing surgical site infection during hospital stay with isolates matching those of nasal swabs in 85% of cases.8 Around 30% of patients identified as MRSA positive develop a subsequent infection.13 Isolation and decontamination are two of the main targeted control measures for reducing the transmission of MRSA. Isolation interrupts cross infection through physical or behavioural barriers such as disposable gloves and aprons (contact precautions) or the placement of patients in isolation wards or single rooms designated for the exclusive care of MRSA infected patients.
Decontamination attempts to eliminate or suppress MRSA using topical and sometimes intranasal antimicrobials, to help reduce the bacterial load available to cause endogenous infection and transmission to other patients. Isolation and decontamination are often combined with screening to detect colonised patients. Early and accurate detection of
A 2017 study undertaken at University Hospitals Birmingham (UHB) NHS Foundation Trust investigated the impact when routine MRSA decontamination in ICU was discontinued. They found a 250% increase in bacteraemia cases across the whole hospital.
colonised or infected patients allows timely implementation of interventions aimed at preventing transmission or infection. A 2011 study concluded that all decontamination strategies in ICU improved health outcomes as well as cutting costs of healthcare provision, but universal decontamination was found to be the most cost effective, provided resistance is lacking.12
It has been documented that
the excessive use of mupirocin for nasal MRSA decolonisation leads to resistance.11 Also the recent observation that MRSA strains carrying the antiseptic resistance genes qacA/B can be clinically resistant to chlorhexidine raises a note of caution against its unfettered use.14
Decontamination helps reduce transmission and prevent disease in Staphylococcus aureus carriers. Using an antimicrobial body wash and nasal gel has been shown to improve health outcomes as well as reduce costs.12
associated Staphylococcus aureus infection in MSSA-carrier patients who ‘were decolonised on admission to hospital fell by nearly 60% compared with placebo’.15 In patients undergoing cardiothoracic or orthopaedic surgery, screening for Staphylococcus aureus nasal carriage and decontaminating carriers resulted in a substantial reduction in hospital costs. This approach resulted in a cost saving of almost £3,000 per cardiothoracic patient compared to the non-screened and non-treated patients.16
A study
in over 74,000 patients demonstrated that universal decontamination is more effective and efficient compared to alternative methods such as screening with selective decontamination. Universal decontamination in adult ICUs led to a 37% reduction in risk of an MRSA clinical isolate and a 44% reduction in risk of bloodstream infections due to all pathogens.10
In a large, randomised multicentre trial, the risk of developing hospital
Decontamination in ICU offers potential infection control benefits not just to the patients in ICU but it also has a positive impact across the whole hospital. A 2017 study undertaken at University Hospitals Birmingham (UHB) NHS Foundation Trust investigated the impact when routine MRSA decontamination in ICU was discontinued. They found a 250% increase in bacteraemia cases across the whole hospital. Six months after reinstating routine decontamination in ICU, cases showed a significant decrease. The researchers concluded that ‘routine decolonisation for MRSA in a large ICU setting is an effective strategy to reduce the spread and incidence of MRSA across the whole hospital’.17 A number of studies have evaluated the efficacy of decontamination with an octenidine-based antimicrobial. In 2013, preventive body washing with an octenidine based antimicrobial was introduced for all patients on a 32 bed ICU which had experienced an increasing number of nosocomial cases despite robust hand hygiene and environmental disinfection measures. The implementation of universal decontamination using an octenidine based antimicrobial in combination with a standardised washing regimen, led to a significant reduction in nosocomial colonisation. Nosocomial incidence density of 7.55 (pre-intervention) was reduced to 2.61 (post-intervention) per 1000 patient days. Nosocomial infections were significantly reduced from 13 cases to 1 case after intervention.18 A two-year retrospective pilot study in a mixed medical and surgical ICU / high dependency unit examined the use of an octenidine based antimicrobial for routine
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WWW.CLINICALSERVICESJOURNAL.COM DECEMBER 2021
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