50 Chapter 3 Compared with topical therapy with mupirocin only, the combination of oral trimethoprim/sulfamethoxazole plus topical fusidic acid (without mupirocin) performed marginally worse in MRSA eradication in hospitalized patients and personnel after 14 days [65]. Rifampin plus novobiocin resulted in a non-significant higher decolonization rate after 14 days compared with rifampin plus trimethoprimsulfamethoxazole (respectively 67% vs. 53%) in an RCT on MRSA-colonized patients and personnel in the United States. Decolonization in both groups was significantly more often achieved in colonization sites other than wounds [67]. However, novobiocin has since been withdrawn from the market. Rifampin with ciprofloxacin was more effective compared with rifampin with trimethoprim/sulfamethoxazole in an RCT on MRSA-colonized patients (50% vs. 37% eradicated after 6 months of follow-up). Only 21 patients were enrolled when the study was terminated because of emergence of ciprofloxacin resistance in the hospital, unrelated to the study [68]. Few studies have been published specifically on systemic MRSA decolonization in the community, mainly from countries with low MRSA prevalence. The previously mentioned Swedish study randomly assigned 52 outpatients with MRSA throat carriage between chlorhexidine, nasal mupirocin, rifampin, and either clindamycin or trimethoprim/sulfamethoxazole (group 1) and chlorhexidine and nasal mupirocin only (group 2). At 6 months of follow-up, 61% of systemically treated vs. 13% of topical treated patients were successfully decolonized (p < 0.01) [31]. In a cohort of Dutch outpatients with extra-nasal MRSA colonization, decolonization treatment combination of chlorhexidine body wash, mupirocin ointment intranasally, and a combination of two systemic antibiotics (mostly rifampin with trimethoprim or doxycycline) was successful in 85% of patients and the vast majority was still negative after 1 year of follow-up [23]. Two Danish cohort studies did not show a benefit of adding clindamycin to decolonization treatment of MRSA throat carriage [74,75]. In the previously discussed Canadian study, a country with high MRSA prevalence, 98 outpatients with MRSA colonization at any site were randomized between a 7-day course of topical treatment alone or supplemented with oral rifampin and doxycycline [32]. The initial success rate was higher in the systemic treatment arm, but this difference had disappeared after 12 months of follow-up. As said, no genotyping was performed to elucidate whether this was because of long-term treatment failure or recolonization with a different strain.
RkJQdWJsaXNoZXIy MTk4NDMw