65 Effectiveness of MRSA decolonization regimens 4 Introduction Methicillin-resistant Staphylococcus aureus (MRSA) is a challenging global health problem. Colonization with MRSA leads to increased infection risks, ranging from mild skin infections to severe clinical syndromes, i.e. pneumonia and bloodstream infection [1-3]. Compared to infections with their more susceptible counterpart, mortality is high in MRSA infections. [4] This may in part be attributed to decreased antibiotic effectiveness and increased toxicity of the antibiotic therapy. Decolonization of MRSA in carriers has proven to be an effective preventive strategy in reducing infection- and hospitalization rates [5, 6]. In Europe, the prevalence of MRSA in Staphylococcus aureus blood isolates was 16.4% in 2018 with large intercountry variations [7]. In the Netherlands, the MRSA prevalence in blood culture isolates is 1.4%, along with the Scandinavian countries one of the lowest in the world [7, 8]. The low prevalence in the Netherlands is to a large part ascribed to the ‘search and destroy policy’, targeting MRSA carriers [9-11]. The aim of this policy is to minimize colonization and transmission in both health care workers (HCWs) and patients. Active screening e.g. after hospitalization abroad, isolation of MRSA carriers and pre-emptive isolation of risk groups are part of this policy [11]. The policy also urges for decolonization treatment in all MRSA carriers. The Dutch guideline for the treatment of MRSA carriage differentiates between complicated and uncomplicated carriership [12]. Uncomplicated carriership, i.e. exclusively located in the nose and without active infection, is advised to be treated with topical therapy (mupirocin topically applied to the nares) and hygienic measures. In case of complicated MRSA carriage additional systemic antimicrobial therapy with a combination of two antibiotic agents is recommended. Due to the limited availability of data [13-17], it has yet remained undecided which combination of anti-staphylococcal agents is most effective. The individual treatment regimen, i.e. the choice of antibiotic agents and treatment duration in clinical practice is therefore variable [18]. The aim of this study was to describe the effectiveness of different MRSA decolonization treatments for complicated MRSA carriage. Table 1: Oral antibiotic combination therapy for decolonization of MRSA colonization according to the Dutch national guideline Antibiotic agent 1 Antibiotic agent 2 Recommended Doxycycline 200mg qd or Trimethoprim 200mg bid Rifampicin 600mg bid Alternative Clindamycin 600mg tid or Clarithromycin 500mg bid or Ciprofloxacin 750mg bid or Fusidic acid 500mg tid Fusidic acid 500mg tid Legend: qd = once a day, bid = twice a day, tid = three times a day.
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