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One size does not fit all: why universal decolonization strategies to prevent methicillin-resistant Staphylococcus aureus colonization and infection in adult intensive care units may be inappropriate for neonatal intensive care units

Journal of Perinatology volume 34, pages 653–655 (2014)Cite this article

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Abstract

The REDUCE MRSA Trial (Randomized Evaluation of Decolonization vs Universal Clearance to Eliminate Methicillin-Resistant Staphylococcus aureus), a large multicenter, randomized controlled trial in adult intensive care units (ICUs), found universal decolonization to be more effective than surveillance and isolation procedures with or without targeted decolonization for reducing rates of MRSA-positive clinical cultures. The Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention subsequently published protocols for implementing universal decolonization in ICUs based on the trial’s methods. Caution should be exercised before widely adopting these procedures in neonatal intensive care units (NICUs), particularly strategies that involve bathing with chlorhexidine and mupirocin application due to the potential for adverse events in their unique patient population, especially preterm infants. Large multicenter trials in the NICUs are needed to evaluate the efficacy, short- and long-term safety, and cost effectiveness of these strategies prior to their widespread implementation.

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References

  1. Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan A et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infect Control Hosp Epidemiol 2013; 34 (1): 1–14.

    Article  PubMed  Google Scholar 

  2. Lessa FC, Edwards JR, Fridkin SK, Tenover FC, Horan TC, Gorwitz RJ . Trends in incidence of late-onset methicillin-resistant Staphylococcus aureus infection in neonatal intensive care units: data from the National Nosocomial Infections Surveillance System, 1995-2004. Pediatr Infect Dis J 2009; 28 (7): 577–581.

    Article  PubMed  Google Scholar 

  3. Huang YC, Chou YH, Su LH, Lien RI, Lin TY . Methicillin-resistant Staphylococcus aureus colonization and its association with infection among infants hospitalized in neonatal intensive care units. Pediatrics 2006; 118 (2): 469–474.

    Article  PubMed  Google Scholar 

  4. Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Avery TR et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013; 368 (24): 2255–2265.

    Article  CAS  PubMed  Google Scholar 

  5. Climo MW, Yokoe DS, Warren DK, Perl TM, Bolon M, Herwaldt LA et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med 2013; 368 (6): 533–542.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Universal ICU Decolonization: An Enhanced Protocol. Prepared by The REDUCE MRSA Trial Working Group ucHiAPN—ER, MD: Agency for Healthcare Research and Quality; September 2013.

  7. Chapman AK, Aucott SW, Milstone AM . Safety of chlorhexidine gluconate used for skin antisepsis in the preterm infant. J Perinatol 2012; 32 (1): 4–9.

    Article  CAS  PubMed  Google Scholar 

  8. O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO et al. Summary of recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis 2011; 52 (9): 1087–1099.

    Article  PubMed  PubMed Central  Google Scholar 

  9. U.S. Food and Drug Administration. Safety Labeling Changes Approved By FDA Center for Drug Evaluation and Research (CDER)—May 2012. 12 June 2012 (cited 12 February 2014). Available from http://www.fda.gov/Safety/MedWatch/SafetyInformation/Safety-RelatedDrugLabelingChanges/ucm307387.htm.

  10. Tamma PD, Aucott SW, Milstone AM . Chlorhexidine use in the neonatal intensive care unit: results from a national survey. Infect Control Hosp Epidemiol 2010; 31 (8): 846–849.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Garland JS, Alex CP, Mueller CD, Otten D, Shivpuri C, Harris MC et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001; 107 (6): 1431–1436.

    Article  CAS  PubMed  Google Scholar 

  12. Lashkari HP, Chow P, Godambe S . Aqueous 2% chlorhexidine-induced chemical burns in an extremely premature infant. Arch Dis Child Fetal Neonatal Ed 2012; 97 (1): F64.

    Article  PubMed  Google Scholar 

  13. Mannan K, Chow P, Lissauer T, Godambe S . Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. Acta Paediatr 2007; 96 (10): 1536–1537.

    Article  CAS  PubMed  Google Scholar 

  14. Chapman AK, Aucott SW, Gilmore MM, Advani S, Clarke W, Milstone AM . Absorption and tolerability of aqueous chlorhexidine gluconate used for skin antisepsis prior to catheter insertion in preterm neonates. J Perinatol 2013; 33 (10): 768–771.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Quach C, Milstone AM, Perpete C, Bonenfant M, Moore DL, Perreault T . Chlorhexidine bathing in a tertiary care neonatal intensive care unit: impact on central line-associated bloodstream infections. Infect Control Hosp Epidemiol 2014; 35 (2): 158–163.

    Article  PubMed  Google Scholar 

  16. Curley A, Kimbrough RD, Hawk RE, Nathenson G, Finberg L . Dermal absorption of hexochlorophane in infants. Lancet 1971; 2 (7719): 296–297.

    Article  CAS  PubMed  Google Scholar 

  17. Kopelman AE . Cutaneous absorption of hexachlorophene in low-birth-weight infants. J Pediatr 1973; 82 (6): 972–975.

    Article  CAS  PubMed  Google Scholar 

  18. Shuman RM, Leech RW, Alvord EC Jr. Neurotoxicity of hexachlorophene in the human: I. A clinicopathologic study of 248 children. Pediatrics 1974; 54 (6): 689–695.

    CAS  PubMed  Google Scholar 

  19. Aggett PJ, Cooper LV, Ellis SH, McAinsh J . Percutaneous absorption of chlorhexidine in neonatal cord care. Arch Dis Childhood 1981; 56 (11): 878–880.

    Article  CAS  Google Scholar 

  20. Cowen J, Ellis SH, McAinsh J . Absorption of chlorhexidine from the intact skin of newborn infants. Arch Dis Childhood 1979; 54 (5): 379–383.

    Article  CAS  Google Scholar 

  21. Garland JS, Alex CP, Uhing MR, Peterside IE, Rentz A, Harris MC . Pilot trial to compare tolerance of chlorhexidine gluconate to povidone-iodine antisepsis for central venous catheter placement in neonates. J Perinatol 2009; 29 (12): 808–813.

    Article  CAS  PubMed  Google Scholar 

  22. Delaney HM, Wang E, Melish M . Comprehensive strategy including prophylactic mupirocin to reduce Staphylococcus aureus colonization and infection in high-risk neonates. J Perinatol 2013; 33 (4): 313–318.

    Article  CAS  PubMed  Google Scholar 

  23. Richter SS, Diekema DJ, Heilmann KP, Dohrn CL, Crispell EK, Riahi F et al. Activity of Vancomycin, Ceftaroline, and Mupirocin Against Staphylococcus aureus from a 2011 National Surveillance Study in the United States. Antimicrob Agents Chemother 2013; 58 (2): 740–745.

    Article  PubMed  Google Scholar 

  24. Fritz SA, Hogan PG, Camins BC, Ainsworth AJ, Patrick C, Martin MS et al. Mupirocin and chlorhexidine resistance in Staphylococcus aureus in patients with community-onset skin and soft tissue infections. Antimicrob Agents Chemother 2013; 57 (1): 559–568.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Khoury J, Jones M, Grim A, Dunne WM Jr., Fraser V . Eradication of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit by active surveillance and aggressive infection control measures. Infect Control Hosp Epidemiol 2005; 26 (7): 616–621.

    Article  PubMed  Google Scholar 

  26. Saiman L, Cronquist A, Wu F, Zhou J, Rubenstein D, Eisner W et al. An outbreak of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2003; 24 (5): 317–321.

    Article  PubMed  Google Scholar 

  27. Sax H, Posfay-Barbe K, Harbarth S, Francois P, Touveneau S, Pessoa-Silva CL et al. Control of a cluster of community-associated, methicillin-resistant Staphylococcus aureus in neonatology. J Hosp Infect 2006; 63 (1): 93–100.

    Article  CAS  PubMed  Google Scholar 

  28. Gerber SI, Jones RC, Scott MV, Price JS, Dworkin MS, Filippell MB et al. Management of outbreaks of methicillin-resistant Staphylococcus aureus infection in the neonatal intensive care unit: a consensus statement. Infect Control Hosp Epidemiol 2006; 27 (2): 139–145.

    Article  PubMed  Google Scholar 

  29. Milstone AM, Song X, Coffin S, Elward A . Society for Healthcare Epidemiology of America's Pediatric Special Interest G. Identification and eradication of methicillin-resistant Staphylococcus aureus colonization in the neonatal intensive care unit: results of a national survey. Infect Control Hosp Epidemiol 2010; 31 (7): 766–768.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Carey AJ, Della-Latta P, Huard R, Wu F, Graham PL 3rd, Carp D et al. Changes in the molecular epidemiological characteristics of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2010; 31 (6): 613–619.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Gregory ML, Eichenwald EC, Puopolo KM . Seven-year experience with a surveillance program to reduce methicillin-resistant Staphylococcus aureus colonization in a neonatal intensive care unit. Pediatrics 2009; 123 (5): e790–e796.

    Article  PubMed  Google Scholar 

  32. Popoola VO, Budd A, Wittig SM, Ross T, Aucott SW, Perl TM et al. Methicillin-resistant Staphylococcus aureus transmission and infections in a neonatal intensive care unit despite active surveillance cultures and decolonization: challenges for infection prevention. Infect Control Hosp Epidemiol 2014; 35 (4): 412–418.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Maraqa NF, Aigbivbalu L, Masnita-lusan C, Wludyka P, Shareef Z, Bailey C et al. Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus colonization and infection among infants at a level III neonatal intensive care unit. Am J Infect Control 2011; 39 (1): 35–41.

    Article  PubMed  Google Scholar 

  34. Seybold U, Halvosa JS, White N, Voris V, Ray SM, Blumberg HM et al. Emergence of and risk factors for methicillin-resistant Staphylococcus aureus of community origin in intensive care nurseries. Pediatrics 2008; 122 (5): 1039–1046.

    Article  PubMed  Google Scholar 

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Acknowledgements

This study was supported in part by a grant from the NICHD, T32 HD007094.

Author information

Authors and Affiliations

  1. Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA,

    M U Nelson, M J Bizzarro & P G Gallagher

  2. Division of Infectious Disease, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA,

    L M Dembry

  3. Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA,

    L M Dembry & R S Baltimore

  4. Department of Infection Control, Yale-New Haven Hospital, New Haven, CT, USA

    L M Dembry & R S Baltimore

  5. Division of Infectious Disease, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA,

    R S Baltimore

  6. Department of Pathology, Yale University School of Medicine, New Haven, CT, USA

    P G Gallagher

  7. Department of Genetics, Yale University School of Medicine, New Haven, CT, USA

    P G Gallagher

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Correspondence to P G Gallagher.

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Nelson, M., Bizzarro, M., Dembry, L. et al. One size does not fit all: why universal decolonization strategies to prevent methicillin-resistant Staphylococcus aureus colonization and infection in adult intensive care units may be inappropriate for neonatal intensive care units. J Perinatol 34, 653–655 (2014). https://doi.org/10.1038/jp.2014.125

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  • DOI: https://doi.org/10.1038/jp.2014.125

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