52 Chapter 3 Future perspectives Concerns about emerging resistance and the impact on the microbiome resulting from current treatment strategies drive the search for alternative, non-antibiotic, decolonization therapies. A recently published phase-two trial showed promising results of oral probiotics for nasal and intestinal S. aureus decolonization, with a 95% reduction of S. aureus colonization without notable changes in the microbiota [76]. Ongoing research is focused on engineering a skin probiotic to selectively combat MRSA colonization [77]. In addition, novel non-antibiotic drugs are being evaluated for their potential in S. aureus eradication, including the porphyrin drug XF-73, the LL-37- derived peptide P10 and SAAP-148 [78-80], and bacteriophage therapy [77]. Despite multiple attempts, vaccines to prevent S. aureus infections have so far not been proven clinically effective [81]. However, the high burden of disease provides grounds to continue the search. Figure 2. Implications of prevalence of MRSA carriage for the approach of the community and individual. In a low CO-MRSA prevalent setting, sustained decolonization of CO-MRSA is feasible and can prevent further spread in the community. This supports the ‘search and destroy’ policy, in which carriers are identified, household contacts screened, and decolonization is attempted. In this setting, this policy is effective in maintaining a low MRSA prevalence. In contrast, in high-endemic regions, there is high risk of recolonization. Consequently, routine eradication treatment of CO-MRSA aiming at achieving a noncarrier state for a prolonged period of time is less likely to be successful. In this setting, a standard ‘search and destroy’ policy is not likely to reduce the high MRSA prevalence, and an individualized approach is more rational. CO-MRSA, community-onset methicillin-resistant Staphylococcus aureus.
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