13 General Introduction 1 Outline of the thesis Optimization of MRSA decolonization Colonization with S. aureus is a risk factor for developing subsequent infections. For bloodstream infections, this results from an endogenous infection source, reflected by identical isolates cultured from the blood and nares of patients with S. aureus bacteremia. Colonization with MRSA increases infection risk even more than colonization with methicillin-susceptible S. aureus (MSSA), in both patients and healthy individuals [18-21]. Decolonization therapy has been proven to reduce S. aureus infections, although the evidence for infection reduction outside of hospital settings is limited [22-24]. In the Netherlands, the MRSA prevalence is one of the lowest in the world [25]. This low prevalence is, next to the restricted use of antibiotics, to a large part ascribed to our ‘search and destroy’ policy [26, 27]. The policy consists of screening and preemptive isolation of patients at risk for MRSA carriership when hospitalized, and subsequent decolonization treatment when persistent carriership is found [28]. The aim of this policy is to minimize MRSA colonization in order to prevent transmission and infection. The effectiveness of the ‘search and destroy’ policy depends on several consecutive steps. First of all, MRSA carriers need to be identified. The second step includes the initiation of eradication treatment. We evaluated barriers in these first steps of MRSA eradication care in chapter 2. The third and final step involves the effectiveness of decolonization treatments, and is addressed in the next two chapters. Despite being notorious for nosocomial transmission and hospital outbreaks, MRSA with onset in the community has emerged over the past decades and has become endemic in large parts of the world [29, 30]. In chapter 3, we reviewed the evidence on individual decolonization strategies for MRSA, with particular emphasis on community-onset MRSA. The Dutch guideline for MRSA eradication distinguishes between uncomplicated and complicated carriership [31]. Complicated carriership is defined as extra-nasal MRSA colonization, colonization with active skin lesions, foreign body material with connection to exterior, or previous failure of eradication treatment. Active skin lesions are recommended to be treated and foreign body material with connection to exterior to be removed before initiation of eradication treatment. Extra-nasal MRSA carriership is recommended to be treated with the combination of topical therapy and two systemic antimicrobial agents. However, which combination of systemic anti-staphylococcal antibiotics is most effective in MRSA eradication has not been clarified yet [32]. In chapter 4, the effectiveness of different MRSA decolonization
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