Today's Clinical Lab - News, Editorial and Products for the Clinical Laboratory
Clinicians with protective masks examine the infected female patient in the ICU who rests on a bed with an oxygen mask.
Studies show that daily bathing with antiseptic chlorhexidine soap plus nasal mupirocin for all ICU patients prevented many bloodstream- and other serious infections.
iStock, RainStar

Decolonization with Mupirocin Prevents MRSA, ICU Infections

Large clinical trial highlights the effect of nasal ointment on S. aureus infection and antibiotic resistance

HCA Healthcare
Published:Oct 10, 2023
|3 min read
Register for free to listen to this article
Listen with Speechify

NASHVILLE, TN — A large multi-state study by the Centers for Disease Control and Prevention, the Harvard Pilgrim Health Care Institute, HCA Healthcare, and the University of California, Irvine, has found that a nasal antibiotic ointment, mupirocin, which is currently used daily for intensive care unit (ICU) patients in only one-third of US hospitals, is highly effective at preventing Staphylococcus aureus infections in critically ill patients, outperforming an antiseptic solution.

This study involved more than 800,000 ICU patients in 137 HCA Healthcare hospitals and built upon an earlier study among these research partners demonstrating that daily bathing with antiseptic chlorhexidine soap plus nasal mupirocin for all ICU patients prevented many bloodstream and other serious infections. 

This strategy is called decolonization because it reduces the amount of bacteria on the body in order to reduce infection risk. Currently, as a result of the previous study, the majority of ICUs bathe patients with chlorhexidine. However, only one-third of hospital ICUs provide nasal mupirocin to all patients, largely due to fears of fueling antibiotic resistance.

Because of a concern that disease-causing bacteria might become resistant to mupirocin, the investigators compared mupirocin to an alternative nasal antiseptic product—povidone-iodine or iodophor.

Randomized trial findings

The Mupirocin-Iodophor Swap Out Trial directly compared nasal mupirocin to nasal iodophor in the context of chlorhexidine bathing. The trial found that mupirocin worked significantly better than the antiseptic in preventing S. aureus infection, including those due to methicillin-resistant S. aureus, or MRSA. The CDC-funded study was published recently in the Journal of the American Medical Association (JAMA).

“This study further supports CDC guidance on using a strategy that combines nasal decolonization plus CHG bathing in ICU patients. Furthermore, the data show that using mupirocin for nasal decolonization may be preferred over iodophor because it is more effective at preventing S. aureus infections or colonization. S. aureus infections account for nearly a quarter of the infections in ICUs in the United States,” said John Jernigan, MD, branch chief of the CDC’s Epidemiology, Research and Innovations Branch.

The results resolved the question about whether nasal treatment is necessary in addition to chlorhexidine bathing to prevent these ICU infections. “This large study confirms that clearing the nose of bacteria prevents infection and that the choice of product matters. Mupirocin antibiotic ointment remains the best treatment, and serious ICU infections can be avoided by simply giving patients mupirocin for the first five days of an ICU stay along with daily chlorhexidine bathing. Povidone-iodine does not work as well,” remarked lead investigator, Susan S. Huang, MD, MPH, professor in the Division of Infectious Diseases at the University of California, Irvine School of Medicine.

Benefits of mupirocin demonstrated

The 137 participating community hospitals spanned 18 states and are part of HCA Healthcare. Half of the hospitals continued their standard practice of treating ICU patients with mupirocin nasal ointment and the other half switched to nasal povidone-iodine. All hospitals used the nasal product for five days plus chlorhexidine for daily bathing.

Importantly, this trial showed a durable benefit from mupirocin. There is persistent clinical benefit even after nearly a decade of continuous ICU use, suggesting that use of chlorhexidine soap and mupirocin had not lost their effect. This is important because widespread antibiotic use can lead to antibiotic resistance in some instances.

Because of the size of the study and the fact that it was conducted at such a wide range of community hospitals, the results are generally believed to be applicable to hospitals across the country.

The same group of researchers had conducted the REDUCE MRSA Trial over 10 years ago, which first showed that this decolonization regimen could reduce MRSA by 37 percent and bloodstream infections by 44 percent. Now, the Mupirocin-Iodophor Swap Out Trial showed that switching from mupirocin to iodophor produced 18 percent less protection from S. aureus infections.

The Mupirocin-Iodophor Swap Out Trial adds to a growing set of evidence that reducing the amount of bacteria on the skin and in the nose through decolonization can protect patients from infection during high-risk moments. The group also showed that decolonization of hospitalized patients with medical devices outside of the ICU reduces both bloodstream infections and antibiotic-resistant pathogens (ABATE Infection Trial).

- This press release was originally published on the HCA Healthcare website