251 General discussion 11 out-of-pocket costs. The most apparent improvements in these steps therefore lie in expanding familiarity with the ‘search and destroy’ policy and incorporating it in a general practitioners’ guideline. In addition, treatment initiation should be made as accessible as possible, for example by facilitating easy referrals and eliminating costs for the individual patient. It is essential to realize that the aforementioned study focuses specifically on the Dutch situation and is not necessarily applicable to the rest of the world. MRSA endemicity varies widely around the globe, significantly impacting the rationale behind decolonization treatments, as described in chapter 3. Due to the high risk of recolonization in the setting of high MRSA prevalence in the community, the likelihood of successful long-term decolonization is low. In this setting, a standard ‘search and destroy‘ policy is not likely to attribute to lowering its prevalence in the population as a whole. Short-term bacterial load reduction aiming at prevention of nosocomial infections and transmission might be appropriate in countries where MRSA is endemic. Nevertheless, a broader approach with nationwide infection control programs is able to reduce the high prevalence of MRSA in healthcare settings drastically, as demonstrated in the United Kingdom at the beginning of this century [6]. Furthermore, individual risk factors for treatment failure contribute to likelihood of successful eradication. Thus, both likelihood of successful durable eradication and treatment goal should guide the eligibility for community-onset MRSA decolonization treatment of the individual patient. The last step in the MRSA cascade of care concerns the effectiveness of decolonization treatments. In chapter 3, we describe the effectivity of different decolonization treatments. The combination of mupirocin and antiseptic body wash is highly effective in decolonization of nasal MRSA carriage but appears to be insufficient in patients with extra-nasal MRSA colonization. Most evidence supports topical therapy combined with rifampin and a second antimicrobial agent for extranasal MRSA eradication. However, the clinical applicability of many studies on MRSA decolonization is hampered by the lack of reporting of the carrier status of household contacts and long-term follow-up cultures. Also, the MRSA colonization rate in the population varies between studies and is believed to be a major driver of recolonization. In this respect, it is of importance that strain genotype is often not reported in case of positive follow up cultures, which makes differentiating between treatment failure and recolonization impossible. Future studies should include these factors, to accurately determine the most effective treatment and the real risk of recolonization in low and high prevalent settings. In order to provide insight in the situation in our region, we evaluated the efficacy of decolonization treatments in complicated MRSA carriership in five Dutch hospitals in chapter 4. We found an overall high success rate, and a trend towards a higher
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