250 Chapter 11 Summary and general discussion Staphylococcus aureus colonizes millions of people, often without causing any symptoms. In contrast, when mucosal or skin barriers are broken, S. aureus becomes a frequent cause of hospital-acquired, healthcare-associated, and communityacquired infections in all age categories. S. aureus disease is highly variable, ranging from mild skin infections to catastrophic bloodstream infections with high mortality rates. Perhaps as a result of this heterogeneity, many questions remain with respect to risk factors, complications, and management. The resistant variant of S. aureus is a major threat to global public health. Methicillinresistant Staphylococcus aureus (MRSA) is a dominant actor in antimicrobial resistance. MRSA colonization increases infection risks, forming the basis for decolonization of MRSA carriers. This thesis addressed the optimization of MRSA decolonization strategies and frequently encountered challenges in S. aureus bacteremia management. The results of the studies described in chapters 2 through 10 will be briefly summarized and discussed in this chapter. Optimization of MRSA decolonization In the Netherlands, we are proud of having one of the world’s lowest rates of MRSA. Less than 5% of invasive S. aureus isolates in our country are resistant to methicillin, compared to up to 25% in our neighboring countries [1]. Yet, given the rising MRSA prevalence in our surrounding countries, the immigration of people from highendemic areas, and the travelling of Dutch citizens towards these regions, it requires our continuous attention. The ‘search and destroy’ policy targeting MRSA is executed in the Netherlands since 1988 and has since been proven to be cost-effective [2, 3]. However, the effectiveness of the ‘search and destroy’ policy as a whole, depends on several consecutive steps. Analogous to the renowned cascade of care for persons living with HIV, that has been frequently used to identify culprits in the uptake of antiretroviral therapy [4, 5], we constructed a cascade of care for MRSA decolonization. Each consecutive step of this conceptual cascade is crucial, since individuals may be lost in every step. The first steps include identification of carriers and the initiation of treatment, and were analyzed in chapter 2. We surveyed 114 general practitioners about their familiarity with the ‘search and destroy’ policy and evaluated barriers in the uptake of MRSA eradication care. Remarkably, the majority of the responding general practitioners were not familiar with the policy. Moreover, they often refrained from starting eradication treatment, for various reasons including lack of recommendation in a general practitioners’ guideline, patients’ burden and
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