It's common hospital practice to screen ICU patients for methicillin-resistant Staphylococcus aureus (MRSA) infection and to isolate those who are infected. A recent study compared that practice with two others: targeted decolonization (screening plus decolonization of patients with MRSA colonization or infection) and universal decolonization (no screening; decolonization of all ICU patients). Decolonization consisted of five days of twice-daily intranasal mupirocin and daily bathing with chlorhexidine-impregnated cloths for the duration of the ICU stay.

A total of 43 hospitals-mostly community hospitals-with adult ICUs participated and were randomly assigned to begin one of the three protocols after a 12-month baseline period.

The odds of seeing positive MRSA cultures were significantly lower in the universal-decolonization group (hazard ratio [HR], 0.63) than in both the isolation group (HR, 0.75) and the targeted-decolonization group (HR, 0.92). Rates of ICU-attributable MRSA bloodstream infection were similar across groups; however, rates of bloodstream infection by any pathogen were significantly lower in the universal-decolonization group than in either of the others. Adverse events, which were extremely rare, were mild itching and rash, which subsided after chlorhexidine bathing ended.

Overall, universal decolonization was most effective and isolation was least effective. The authors believe that may be because the decolonization process protects patients from their own microbiota and reduces microbial transmission, and because the intervention was carried out on each patient's first day in the ICU rather than after screening test results were obtained. They recommend that a cost-effectiveness analysis be undertaken to compare screening and isolation with universal decolonization. Of importance, the authors note that universal decolonization could promote resistance, something that will have to be monitored closely if the practice is widely adopted.

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