66 Chapter 4 Methods A multicenter retrospective cohort study was conducted in five Dutch hospitals (one university hospital and four large regional teaching hospitals). Study population All consecutive patients referred to the outpatient clinic with complicated MRSA colonization from January 2014 until December 2018 were eligible for inclusion. Exclusion criteria were the absence of MRSA colonization upon screening at the outpatient clinic, uncomplicated carriership and a patient’s objection to the use of his medical file for research purposes. Outpatient clinic History taking and physical examination were performed during the first visit to the outpatient clinic. Physical examination included skin examination, as skin lesions such as eczema may impede effective decolonization. Furthermore, physical examination involved examination of the oral cavity. Culture swabs were routinely obtained from nose, throat and perineum. If skin lesions e.g. wounds were present, additional cultures were obtained from these sites. Household contacts were screened as well, and colonized household contacts were treated simultaneously and were included in the study. The standard treatment consisted of nasal mupirocin thrice daily, topical disinfectants daily (chlorhexidine soap and betadine shampoo) and hygienic measures. Hygienic measures included daily change of underwear, clothes and towels as well as change of bed linen on day 1, 2 and 5. The first choice recommended systemic antibiotic agent combinations were doxycycline-rifampicin and trimethoprim-rifampicin, according to the in vitro susceptibility (12). Alternative combinations were either rifampicin or fusidic acid in combination with clindamycin, clarithromycin or ciprofloxacin, or rifampicin and fusidic acid (Table 1). Standard duration of antibiotic treatment was a minimum of 7 days. Microbiological methods Culturing and susceptibility determination was performed according to the Dutch Society of Medical Microbiology guideline for laboratory detection of highly resistant microorganisms. Minimum inhibitory concentration (MIC) breakpoints and zone diameter breakpoints for resistance and intermediate sensitivity were based on EUCAST criteria (19).
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