44 Chapter 3 Results Determining eligibility for eradication treatment An important but complex question remains, which MRSA carriers should undergo eradication treatment. Worldwide differences in policies and attitudes towards MRSA carriage in the community exist between non-endemic and endemic areas. In countries with high MRSA prevalence, e.g. the United States, eradication treatment is not routinely recommended [16]. Some countries with low MRSA prevalence, e.g. the Netherlands and Denmark, successfully implemented a nationwide ‘search and destroy’ policy in the 1980s, targeting MRSA colonization [17,18]. This policy consists of screening and pre-emptive isolation of patients with an increased risk of MRSA carriage when hospitalized and subsequent decolonization treatment when persistent carriage is found. Two years after eradication treatment, 87% of CO-MRSA carriers in a non-endemic setting remained MRSA negative [19]. A major limitation in the generalizability of a ‘search and destroy’ approach to regions with high MRSA prevalence in the community is the high risk of recolonization. Currently, in countries with endemic MRSA, short-term S. aureus load reduction is often pursued to reduce infection risk in intensive care unit and surgical patients, either universally or targeted at MRSA carriers (or both MRSA and MSSA carriers) after screening [20]. This temporary suppression of MRSA is efficient in presurgical circumstances [21], but to prevent CO-MRSA transmission, complete eradication is desirable. At an individual level, risk factors for failure of decolonization therapy can be a reason to refrain from pursuing this goal. Known risk factors for failure are indwelling catheters or medical devices, skin lesions, colonization of household contacts, chronic pulmonary disease, and an immunocompromised status [22,23]. As a result, two main factors should guide the decision for eradication therapy in an individual patient. First, the treatment goal, which can be either long-term eradication to prevent community transmission and infections, or short-term load reduction to prevent nosocomial infections and transmission. Second, the likelihood of long-term success of decolonization treatment, influenced by both the presence of individual risk factors for failure and the prevalence of MRSA in the environment, driving the risk of recolonization (Figure 1). Lastly, when considering eradication treatment, potential adverse effects should be weighed in. This includes well-known effects such as (hepato-)toxicity and risk of Clostridioides difficile infection, but also newer insights such as potential disruption of the human microbiome [24].
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