Running head: PREVENTION OF MRSA INFECTION 1

Prevention of MRSA Infection

Micayla Coons

University of South Florida

Abstract

Clinical Problem: MRSA is an antibiotic resistant bacteria, it is becoming a common problem

within hospitals for the MRSA bacteria to be transmitted between patients on floors. The

diagnosis of MRSA is not taken lightly; the infection can progress rapidly and cause loss of skin

muscle and bone. The standard protocol at many hospitals is to use isolation and precaution

measures when dealing with a patient that is MRSA positive. This means that anyone entering

the patients room wears a gown and gloves, and the patient is in a private room.

Objective: To provide statistically significant evidence that the use of chlorhexidine bathing as

well as use of isolation and standard precautions on MRSA positive patients decreases the

transmission of and ultimately incidence rate of MRSA.

Results: Camus et al. (2014) found that the use of chlorhexidine bathing with mupirocin nasal

swabs resulted in a 59% decrease in the incidence of MRSA as compared to standard precautions

and isolation (p=.05). Climo et al. (2013) found that the use of chlorhexidine bathing resulted in

a 23% decrease in MRSA and VRE incidences as compared to the control group which practiced

standard precautions and isolation (p=.03). Finally Huang et al. (2013) found there to be a 25%

decrease of MRSA acquisition from the baseline time period with targeted chlorhexidine bathing,

and with universal chlorhexidine bathing there was a 37% decrease from baseline (p= .01).

Conclusion: The results of all three of these studies are conclusive with the hypothesis that

chlorhexidine bathing reduces the incidence rate of MRSA in the hospital setting. The use of

standard precautions and isolation should still be used in conjunction with chlorhexidine bathing.

However more research will most likely need to be done in order to make this a standard

universal protocol.
PREVENTION OF MRSA INFECTION 3

Prevention of MRSA Infection

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common health

care associated pathogens. According to the CDC there are over 80,000 invasive MRSA

infections, and 11,285 MRSA related deaths occur each year. Most hospitals place a patient with

a positive MRSA screening on isolation and precautions. The biggest concern with MRSA

bacterium is that the bacterium is resistant to many antibiotics used to treat staphylococcus

infections, making the bacteria difficult to get rid of. The other concern is that the MRSA

bacterium is often quick in progressing to serious infections of the bones, skin, heart and lungs,

these infections can become so serious they are life threatening. In admitted ICU patients how

well does chlorhexidine bathing compared to standard precautions and isolation prevent the

acquisition of MRSA?

Literature Search

The randomized controlled trials used as the evidence for this research was found on the

database PubMed. The terms used for searching were MRSA, chlorhexidine bathing, standard

isolation, and precautions. The research used was also found by limiting the search terms to only

articles that are a randomized controlled trial, conducted only on humans, and the article being

published within the last five years.

Literature Review

According to the National Institute for Health and Clinical Excellence the interventions

and practices for preventing and controlling healthcare associated infections including MRSA in

the hospital setting include eight different intervention categories. The categories are (1) general

advice such as educating patients of infection prevention and hand decontamination procedures,

(2) hand hygiene, such as washing technique, and use of decontamination agents, (3) use of
PREVENTION OF MRSA INFECTION 4

personal protective protocol, such as gloves gown, facemasks, and eye protection, (4) use and

disposal of sharps, using needle safety devices and immediately disposing of sharps, (5) waste

disposal, including properly discarding waste into the appropriate disposal container, and

labeling, storing and transferring waste according to policy, (6) properly caring for patients with

long term urinary catheters, meaning educating the patient and their caregivers, using the proper

catheter, and assessing the catheter, (7) proper care during enteral feeding, including using proper

technique storing and administering feeds, as well as care of and insertion of the tube, and (8)

proper care of patients with central venous catheters, such as educating patients and caregivers,

using proper technique for general asepsis, sterile catheter site care, and proper catheter

management.

The study by Camus et al. (2014) was conducted to test whether the use of mupirocin and

chlorhexidine decontamination or polymyxin and tobramycin decontamination would reduce the

infection rate of MRSA within the ICU. The study was a randomized controlled trial, and the

measure was incidence rates of MRSA. Five hundred fifteen patients in three hospitals

participated in the study. The polymyxin/tobramycin (P/T) group n=130, the mupirocin/

chlorhexidine (M/C) group n=130, the group receiving both active regimens n=129, and the

placebo only group n= 126. The study resulted in mupirocin/ chlorhexidine having a 59%

decrease in MRSA incidence in comparison to the placebo group with a p=.05. The tobramycin/

polymyxin group resulted in a 290% increase in the incidence rate of MRSA from the placebo

group. This study was conducted double blindly, so neither the hospital, the nurse, or the patients

knew what treatment they were receiving, this was a major strength of the study. The weakness

of the study is that the study had to change its way of analysis to if the patient either received

mupirocin/ chlorhexidine, or didnt, and either received polymyxin/ tobramycin or didnt,

because the original analysis did not hold statistical significance between the two regimens. This

changed the sample numbers to M/C n=259, no M/C n=256, and P/T n=259, and no P/T n=256.

The study by Climo et al. (2013) was conducted to test the hypothesis that bathing

patients daily with chlorhexidine gluconate will reduce the amount of MRSA and VRE in

patients in the ICU. The study was conducted as a randomized controlled trial, with the measures

being incidence rate of MRSA in nare swabs, and incidence rates of VRE in perirectal swabs.

There were 7,727 patients that participated in the study. The study was conducted in nine ICU

units in even hospitals. Five units were assigned to be the chlorhexidine group, and four units

were assigned to be in the control group, which practiced standard precautions and isolation. The

study resulted in a 23% decrease in MRSA and VRE in the intervention group compared to the

control group with a p= .03. The major strength of this study is that the provider of the

washcloths provided educational and technical teaching to the nurses using the wipes so that the

method of bathing was the same throughout. Another strength is that the provider had no

knowledge of the details of the study. The major weakness of the study is that the study was

halted for a while because the provider was recalling the chlorhexidine wipes; the units assigned

to the chlorhexidine intervention group reverted to the use of isolation and standard precautions

during the break. All of the data from that time period was removed from the study, and it was

ruled as a break in the study. Another weakness is that all of the units were not the same type of

ICU, and the differences in patients illness and severity of illness could effect the rate of MRSA

and VRE.

The final study by Huang et al. (2013) was conducted to test whether screening and

isolation, targeted decolonization, or universal decolonization reduced the rate of MRSA in the

patients in the ICU. The study was conducted as a randomized controlled trial and the
PREVENTION OF MRSA INFECTION 6

measurement was incidence rates of MRSA in the cultures of ICU patients. The sample for the

study consisted of 74 ICUs from 43 hospitals. The hospitals were divided into three groups,

group 1 which used the method of isolation and standard precautions, group 2 which used the

method of targeted decolonization, and group 3 which used the method of universal

decolonization. Group 1 had 16 hospitals with 23 ICUs and 23,480 patients. Group 2 had 13

hospitals with 20 ICUs and 22,105 patients. Group 3 had 13 hospitals with 29 ICUs and 26,024

patients. The study resulted in a 37% decrease in MRSA from baseline for universal

decolonization, a 25% decrease in MRSA from baseline for targeted decolonization, and an 8%

decrease in MRSA from baseline for isolation and standard precautions, with a p= .01. The major

strength of this study is that the method of randomization took into account the number of ICU

beds in each hospital, and the prevalence of MRSA in those hospitals before. This made the

distribution more even. Another major strength of the study is that the study was conducted first

with a 12-month baseline period where data was collected with no type of interventions. The

major weakness of this study is that the hospitals and nurses providing care were not blind to the

study, and they knew the intervention they were providing to their patients.

Synthesis

All three of the studies show that the use of chlorhexidine bathing resulted in a decrease

in MRSA incidence rates. In the Camus et al. (2014) study the testing was slightly different from

the others because patients received not only chlorhexidine but also mupirocin, and in some

occasions the patient also received polymyxin and tobramycin. However because the tobramycin

and polymyxin showed an increase in MRSA rates from the placebo group, the patients receiving

both probably did not have an advantage over the patients receiving only

mupirocin/chlorhexidine. The Climo et al. (2013) study was different from the other studies
PREVENTION OF MRSA INFECTION 7

because the measure being tested was not only MRSA acquisition, but VRE acquisition as well.

This too does not change the effectiveness of the evidence because it only proves that the

chlorhexidine bathing is not only beneficial in preventing MRSA but also in preventing VRE.

The third study by Huang et al. (2013) was conducted slightly differently as well. This study was

done with three groups one for targeted decolonization, one for standard precautions, and one for

universal decolonization. The study proved that not only does giving people positive for MRSA

chlorhexidine baths reduce the rates of MRSA, but that giving everyone on floor MRSA positive

or not a chlorhexidine bath reduces the MRSA rates even more. All of the studies were

conducted using the chlorhexidine in the form of a wipe used for bathing patients, it was never

administered as a cream or medication ingested. However the studies should be conducted in a

way that the population is more precise on who the intervention works for. Such as all patients

should be from the same type of ICU whether it be the orthopedic ICU or the cardiovascular

ICU, so that the results represent a specific population, this is one gap these studies had.

The clinical guidelines do not take into effect the use of chlorhexidine. The guideline for

preventing infection is more so aimed at the universal population, and not on patients with a

resistant bacterium. All of the interventions on the clinical guideline fit the description of what

hospitals currently do with isolation and standard precautions. The guideline discussed the use of

gloves and gown, as well as proper hand washing, but it does not discuss the use of

decontamination agents such as chlorhexidine for the patients bathing. The guidelines should

certainly still be used with patients positive of MRSA as well as the chlorhexidine bathing.

Clinical Recommendations

The results of these studies point to the original hypothesis that chlorhexidine bathing

greatly decreases the transmission of and incidence rates of MRSA within the hospital setting as
PREVENTION OF MRSA INFECTION 8

compared to isolation and standard precautions. These are however only three randomized

controlled trials, although the evidence is pointing in the right direction more studies should be

done before a change in protocol is made. The studies should also be conducted in ICUs with

similar patients, like having the sample be solely patients in the neurological ICU, or CCU.

There are always the future problems to consider as well. The bacterium has grown resistant to

many antibiotics used against it, so this bacterium could adapt and become resistant to

chlorhexidine as well. For this reason universal decolonization may not be the best idea, the

decontamination bathing should only be used for targeted decolonization when the patient has a

positive MRSA culture. If the results of these studies continue to be evidential in the use of

chlorhexidine bathing with MRSA patients clinical practice should in turn be revised to include

the decontamination bathing as a standard of practice.

References

Cable News Network Library. (June 11 2015) MRSA fast facts. Retrieved

from:http://www.cnn.com/2013/06/28/us/mrsa-fast-facts/

Camus, C., Sebille, V., Legras, A., Garo, B., Renault, A., Corre, P., . . . Donnio, P. Y. (2014,

January). Mupirocin/chlorhexidine to prevent methicillin-resistant staphylococcus aureus

infections: Post hoc analysis of a placebo controlled, randomized trial using

mupirocin/chlorhexidine and polymyxin/tobramycin for the prevention of acquired

infections in intubated patients. The Springer Journal, 42(3), 493-502.

doi:10.1007/s15010-013-0581-1.

Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., Weinstein,

R. A. (2013, February). Effect of daily chlorhexidine bathing on hospital acquired

infection. The New England Journal of Medicine, 368(6), 533-542.

doi:10.1056/NEJMoa1113849.

Huang, S. S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T. R., . . . Lankiewicz, J.

(2013, June). Targeted versus universal decolonization to prevent icu infections. The New

England Journal of Medicine, 368(24). 2255-2265. doi:10.1056/NEJMoa1207290.

National Institute for Health and Clinical Excellence (NICE). Infection. Prevention and control

of healthcare-associated infections in primary and community care. London (UK):

National Institute for Health and Clinical Excellence (NICE); 2012 Mar. 47p. (Clinical
PREVENTION OF MRSA INFECTION 10

guideline; no.139). Retrieved from: http://www.guideline.gov/content.aspx?

id=36680&search=mrsa+prevention