43 Eradication of community-onset MRSA carriage 3 Introduction Methicillin-resistant Staphylococcus aureus (MRSA) is the leading cause of mortality attributable to antimicrobial resistance [1]. The pathogen is notorious for its nosocomial transmission and hospital outbreaks. On top of that, community-onset MRSA (CO-MRSA) has emerged over the past decades and has become endemic in large parts of the world [2]. Although often carried asymptomatically in the anterior nares, skin lesions, and elsewhere, S. aureus is an important cause of severe infections such as bacteraemia. Isolates cultured from blood and the nares are identical in the large majority of patients with S. aureus bacteraemia, suggesting an endogenous infection route [3]. Colonization with MRSA increases infection risk even more than colonization with methicillin-susceptible S. aureus (MSSA), in both patients and healthy individuals [4-7]. In a North-American cohort of almost 30 000 patients who underwent MRSA screening at hospital admission, MRSA carriers had a 20-fold increased odds of developing MRSA bacteraemia compared with non-carriers [8]. In healthy athletes and soldiers, CO-MRSA colonization was associated with a notable increased risk for developing skin and soft tissue infections [4,9]. Decolonization therapy has been proven to reduce S. aureus infections in hospitalized patients, most pronounced in surgical patients [10-13]. Although evidence is limited, a 1-year survival benefit of S. aureus decolonization before clean surgical procedures is reported [14], as well as cost-effectiveness of active surveillance and decolonization at hospital admission [15]. However, data on the effectiveness of individual decolonization strategies in COMRSA carriage are scarce. This review discusses the evidence concerning strategies for elimination of MRSA colonization, with particular emphasis on CO-MRSA. Methods We searched PubMed from inception to 31 July 2023, using a combination of keywords to capture MRSA, colonization, and decolonization (search strategy in supplement). In addition, we hand-searched key references and international guidelines to identify citations not captured in the PubMed search. Screening was performed by one reviewer, and in case of uncertainty, a second reviewer was consulted. We screened 1335 titles and abstracts, and 129 articles were selected for a comprehensive full-text review. Studies published in languages other than English were excluded in the fulltext review phase. Finally, 66 studies were included in this review. All studies were compiled in EndNote.
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