Infection Control Today

JUN 2019

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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27 June 2019 ICT Biomedical Research Institute at Harbor-UCLA, and Rush University. In addition to AHRQ funding, the study was also supported by the University of California Irvine Institute for Clinical and Translational Science, which was funded by a grant from the National Institutes of Health Clinical and Translational Sciences Award Program. "Our goal was to understand whether removing MRSA from the skin, nose and throat was better than hygiene education alone in reducing MRSA or other infections and associated hospitalizations," says Mary Hayden, MD, professor of internal medicine and pathology, chief of the Division of Infectious Diseases, and director of the Division of Clinical Microbiology at Rush University Medical Center. The researchers followed the patients for 12 months after they were discharged from the hospital, meeting with them in their homes or in a research clinic four times and conducting an exit interview at the end of the year. They also contacted the participants monthly, asked them to report any hospitalizations or clinic visits for infection and reviewed their medical records from the study period. CDC data have shown that MRSA carriers who are discharged from hospitals are at high risk of serious disease due to MRSA in the year following discharge. Approximately 5 to 10 percent of hospitalized patients are MRSA carriers. "With an issue this large, we wanted to fnd best practice strategies to prevent these infections and associated hospitalizations," says Hayden. "This large clinical trial helped determine that there is a way to help prevent infections after patients go home and it can prevent readmission." In another study published in The Lancet in March, Huang and Septimus, et al. (2019) found that daily bathing with an antiseptic soap, plus nasal ointment for patients with prior antibiotic resistant bacteria, reduced hospital acquired infections among patients with central venous catheters and other devices that pierce the skin, according to results of the ABATE Infection Trial. The trial was a 53-hospital randomized trial involving approximately 340,000 patients led by researchers from the Harvard Pilgrim Health Care Institute, the University of California Irvine, Rush University and HCA Healthcare (HCA). The trial was conducted in hospitals affliated with HCA Healthcare and consisted of a 12-month baseline period from March 1, 2013, to Feb 28, 2014, a two-month phase-in period from April 1, 2014, to May 31, 2014, and a 21-month intervention period from June 1, 2014, to Feb 29, 2016. Hospitals were randomized, and their participating non-crit- ical-care units assigned to either routine care or daily chlorhexidine bathing for all patients plus mupirocin for known MRSA carriers. The primary outcome was MRSA or vanco- mycin-resistant enterococcus clinical cultures attributed to participating units, measured in the unadjusted, intention-to-treat population as the HR for the intervention period versus the baseline period in the decolonization group versus the HR in the routine care group. The ABATE Infection Trial evaluated whether daily bathing with an antiseptic soap for all patients, plus nasal mupirocin antibiotic ointment in the nose of patients with a history of MRSA, reduced hospital infections and antibiotic-resistant bacteria. The investigators found that patients with devices, such as central venous catheters, midline catheters, and lumbar drains, benefitted from the intervention, while there was no signifcant beneft in the entire population of non-ICU patients. These patients with devices experienced a 30 percent decrease in bloodstream infections and a nearly 40 percent decrease in antibiotic resistant organisms, specifcally MRSA and vancomycin-resistant enterococcus. Patients with these devices are at higher risk for infection and that may explain why they beneftted. Overall, patients with devices account for over half of all bloodstream infections that occur in the hospital setting. "Several ICU trials have shown striking reductions in infections and antibiotic resistant bacteria using daily chlorhexidine bathing and nasal decolonization with mupirocin. We wanted to know if patients outside the ICU could beneft from a similar decolonization strategy," says Huang. "Until additional data becomes available, we believe it will be worthwhile to adopt this decolonization strategy as best practice in non-ICU patients with devices like these to reduce bloodstream infection and antibiotic resistant organisms," says senior author Richard Platt, MD, MSc, professor and chair of the Department of Population Medicine at the Harvard Pilgrim Health Care Institute and Harvard Medical School. "Following the ICU trials, many hospitals adopted antiseptic bathing for patients with devices outside of the ICU ahead of scientifc evidence to do so. This trial provides support for that strategy, while also pointing to the need for additional information." The researchers note, "Although previous single-center, quasi-experimental studies in non-ICU settings found broad infection reduction benefts with daily chlorhexidine use in patients in academic hospitals, the ABATE Infection trial did not fnd signifcant benefts in non-critical-care patients. Our results contrast with those showing benefts of universal decolonization over routine care in several trials of ICUs. Current U.S. ICU guidance to use daily chlorhexidine bathing for prevention of central line-associated infections has led many hospitals to adopt daily chlorhexidine bathing for all patients with central lines and other devices, although evidence in non-ICU patients has been lacking. The post-hoc analysis in the ABATE Infection trial found that non-ICU patients with medical devices had a signifcant 37 percent reduction in MRSA and VRE and a signifcant 31 percent reduction in all-cause bloodstream infections. Patients with medical devices constituted only 10 percent of the inpatient population but were responsible for 37 percent of MRSA and VRE cultures and 56 percent of all-cause bloodstream infections. Despite these fndings, further research is needed to confrm these effects if the decolonization strategy is applied only to patients with medical devices, since the ABATE Infection trial involved universal decolonization in all patients." The researchers acknowledge the trial's limitations: "Firstly, the study population consisted of patients in general medical and surgical units in community hospitals, where less than 3 percent had a known history of MRSA or VRE. A population with a higher prevalence or risk of multidrug-resistant organisms or infection could have yielded a different outcome. Secondly, although we have daily nursing documentation of whether chlorhexidine bathing or showering occurred, we have less assurance of the quality of chlorhexidine application to the skin, because we only required direct observation of the quality of bathing three times per unit per three-month period during the trial. Compared with ICUs, where decolonization has been highly effective in reducing multidrug-resistant organisms and all-cause bloodstream infections, bathing in non-critical-care units is commonly done by nursing assistants rather than nurses. Additionally, patients often opt for their own application of disposable bathing cloths and soap in showers, and thus the quality of application to the skin is likely highly variable. Lastly, the beneft found in the subpopulation of patients with medical devices was a post-hoc analysis and the trial was not originally designed or powered for this evaluation. Any application of chlorhexidine to this or other subpopulations warrants periodic assessment for the emergence of antiseptic resistance over time." Reference: Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Heim L, et al. Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all- cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster- randomized trial. The Lancet. March 5, 2019.

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