47 Eradication of community-onset MRSA carriage 3 All RCTs on topical MRSA eradication treatment are summarized in Table 1 [26,27,29,46-53]. Very high MRSA decolonization success rates have been reported with mupirocin treatment in a prospective study in hospitalized patients (98%), and an RCT involving long-term care facility residents (93%) [53,54]. Furthermore, in a retrospective analysis of MRSA-colonized patients who were readmitted during the study period, mupirocin was associated with being MRSA negative at readmission, compared with no treatment [55,56]. Focusing specifically on MRSA eradication in the community, little evidence is available on the effectiveness of mupirocin [57]. In an RCT involving 134 healthy MRSA-colonized American soldiers, mupirocin led to 88% nasal eradication compared with 65% with placebo after 8 weeks of follow-up [51]. Similarly, in 87 German hospital workers with nasal MRSA colonization, who were withdrawn from work until MRSA free, treatment with mupirocin nasal ointment and antiseptic mouth rinse and body wash resulted in successful eradication in 84% at 3 months of follow-up [58]. Prolonged mupirocin decolonization treatment (twice monthly for 5 days during 6 months) after discharge in patients that had been hospitalized in the United States with MRSA infections led to a higher decolonization rate compared with placebo (OR of colonization ΒΌ 0.44) [46]. Conflicting results on the effectiveness of mupirocin in CO-MRSA have been reported in regions with high MRSA prevalence, which may be indicative of an increased risk of recolonization rather than treatment failure. In an RCT comparing topical with systemic treatment in patients treated at a dedicated MRSA outpatient clinic, initial decolonization was achieved in 13 of 25 patients who received topical treatment, but this decreased to three after 12 months [32]. The vast majority of patients in this study were colonized at multiple body sites. Seven days of mupirocin nasal ointment combined with antiseptic body wash compared with placebo did not improve decolonization rate in 49 outpatients living with HIV in a RCT [50]. In addition, in a study involving 223 households with ambulatory MRSA skin and soft tissue infections, persistent MRSA colonization was similar in households with and without topical decolonization after 6 months of follow-up [49]. A concern with the use of mupirocin is the emergence of mupirocin resistance [59]. The prevalence of mupirocin resistance varies widely and is reported to be associated with its increased use [60]. Remarkably, a post-hoc analysis of the REDUCE-MRSA trial showed an overall low prevalence of mupirocin-resistant isolates and no increase after mupirocin decolonization treatment [61].
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