Management of Recurrent MRSA Infections

Introduction to MRSA Infections

• The Infectious Diseases Society of America (IDSA) recommends considering decolonization therapy for patients with recurrent skin and soft tissue infections despite optimized wound care and hygiene measures, as well as for ongoing transmission among household members or close contacts despite hygiene measures 1, 2

Decolonization Therapy

• Nasal decolonization with mupirocin 2% ointment applied to the anterior nares twice daily for 5-10 days is a recommended treatment option, with a strength of evidence supporting this recommendation 1, 2
• Body decolonization options include chlorhexidine gluconate 2-4% body washes daily for 5-14 days or dilute bleach baths (1 teaspoon per gallon of water or ¼ cup per ¼ tub) for 15 minutes twice weekly for up to 3 months, with the latter being supported by the IDSA 1
• A 10-dose regimen (twice daily for 5 days) of mupirocin 2% ointment is superior to shorter regimens, with 89.5% of patients remaining decolonized for at least four weeks after therapy, as recommended by the IDSA 2
• The recommended approach for MRSA decolonization is a combination of intranasal mupirocin 2% ointment applied twice daily for 5-10 days plus topical antiseptic body decolonization using chlorhexidine washes or dilute bleach baths, as suggested by the IDSA 1, 2
• Good personal hygiene with regular bathing, maintaining good personal hygiene with regular bathing, and cleaning hands regularly with soap and water or alcohol-based hand sanitizer is recommended alongside mupirocin treatment, as advised by the IDSA 2, 1
• Focus cleaning on high-touch surfaces (counters, doorknobs, bathtubs, toilet seats) and use commercially available cleaners according to label instructions, as recommended by the IDSA 1
• Avoid sharing personal items (razors, towels, linens) and keep draining wounds covered with clean, dry bandages, as advised by the IDSA 1, 2

Screening and Surveillance Cultures

• Screening cultures prior to decolonization are not routinely recommended if at least one prior infection was documented as MRSA, according to the IDSA 1
• Surveillance cultures following decolonization are not routinely recommended in the absence of active infection, and monitor for mupirocin resistance, which has been increasing 1
• The World Health Organization (WHO) guidelines, based on a Cochrane review, found no clear evidence that mupirocin was more effective than fusidic acid for superficial skin infections (RR, 1.03; 95% CI, 0.95-1.11) 3

Household Contacts and Decolonization Failure

• Household contacts should be evaluated for evidence of S. aureus infection if there is ongoing transmission, and treated symptomatic contacts should be considered for decolonization following treatment, as recommended by the IDSA 1, 2
• Using mupirocin alone without addressing body colonization or environmental factors may lead to treatment failure, and decolonization without concurrent hygiene measures is less likely to be successful 1
• Continue reinforcement of hygiene measures alongside decolonization strategies to prevent reinfection, as suggested by the IDSA 1
• Implementing MRSA monitoring programs and contact precautions for colonized patients is recommended in healthcare settings, according to the American Cancer Society, to prevent transmission 4

Pre-operative Decolonization and Oral Antibiotics

• Pre-operative decolonization for high-risk surgeries, such as orthopedic, cardiac, or neurosurgical procedures, is recommended by the Clinical Microbiology and Infection society 5
• Screen patients for MRSA colonization prior to elective procedures, especially high-risk surgeries, as suggested by the Clinical Microbiology and Infection society 5
• Complete decolonization 1-2 weeks before surgery, as recolonization commonly occurs, and consider vancomycin (15 mg/kg 2 hours before surgery) in addition to standard prophylaxis for MRSA carriers undergoing surgery 5
• Oral antibiotics for decolonization should only be considered when topical measures have failed despite good adherence, recurrent MRSA infections continue despite topical decolonization, or multiple body sites are colonized 1
• If oral antibiotics are necessary, options include rifampin-based combinations (with TMP-SMX or doxycycline) and short courses (5-10 days) to minimize resistance development 1
• Alternative treatment includes oral clindamycin 150 mg daily for 3 months, which can decrease subsequent infections by about 80% in cases of susceptible S. aureus, as suggested by the IDSA 6
• Monthly application of mupirocin (5-day course each month) may reduce recurrent infections by approximately 50% in patients with recurrent MRSA infections despite initial decolonization 2, 6