49 Eradication of community-onset MRSA carriage 3 Legend: Chx, chlorhexidine; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillinsusceptible Staphylococcus aureus; SSTI, skin and soft tissue infection. a In days. b N = nasal, A = axilla, G = groin, T = throat, P = perineum/rectum, W = wounds/skin lesions, S = sputum, U = urine. Given the risk of the emergence of mupirocin resistance, alternative topical therapies have been evaluated. Medical-grade honey was only marginally inferior to mupirocin in decolonizing nasal MRSA colonization in a small RCT [47]. Topical therapy with tea tree preparations was significantly less effective compared with mupirocin-based topical therapy for the clearance of intranasal MRSA colonization [52]. Polyhexanide was not effective in MRSA decolonization compared with placebo in an RCT [48], and inferior to mupirocin and chlorhexidine in a retrospective analysis [62]. Efficacy of decolonization therapy with addition of systemic antibiotics Using systemic antibiotics in addition to the topical treatment for MRSA decolonization is common practice in case of extra-nasal colonization in some countries, reserved for cases of topical treatment failure in others, and seldom or never employed in a third category of countries. Most studies on systemic treatment for MRSA decolonization have been performed in health care settings, with a high heterogeneity of treatment agents and control groups. All RCTs on systemic MRSA eradication treatment are summarized in Table 2 [31,32,63-68]. The combination treatment consisting of antiseptic body wash, intranasal mupirocin, rifampin, and trimethoprim/sulfamethoxazole or doxycycline was highly effective in MRSA decolonization of hospitalized patients [63,69,70]. In a small RCT in longterm care facilities in the United States, rifampin monotherapy was superior to no treatment, as well as to minocycline monotherapy. Combination therapy with rifampin and minocycline was not superior to rifampin alone. The majority of patients had decubitus and indwelling catheters, and after 3 months only half of the treated patients remained MRSA negative [66]. Moreover, the risk of emerging resistance when using rifampin monotherapy makes this an inappropriate approach. Another randomized trial on oral fusidic acid monotherapy or no treatment showed no difference in MRSA decolonization rate in 16 intensive care unit patients. However, the study was terminated because of emergence of fusidic acid-resistant strains [64]. Two cohort studies on trimethoprim/ sulfamethoxazole plus rifampin in hospitalized patients resulted in 64e66% successful MRSA decolonization [71,72]. Oral vancomycin, combined with topical therapy, was effective in eradicating MRSA- colonized staff and residents of a nursing home during an outbreak, although 80% experienced side effects [73].
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