We have used a mathematical model to investigate the effects of isolation strategies for patients and of decolonization for patients and HCWs. Our findings demonstrate that – with similar levels of efficacy - patient decolonization is more effective than patient isolation and that active decolonization of persistently colonized HCWs only has a significant impact if a considerable proportion (e.g., 50% or more) of the MRSA acquisitions by patients can be ascribed to persistently colonized HCWs.
Our analyses clearly illustrate the two processes that determine the potential role of persistently colonized HCWs in MRSA transmission. One of these parameters, the proportion of HCWs being colonized, can easily be determined. Reported point-prevalence rates of HCW colonization in the nares range from <0.1% in Dutch hospitals with low endemic levels of MRSA [17
] to 5-6% in hospitals with high endemic levels [18
]. The other parameter, though, the relative contribution of these colonized HCWs for MRSA acquisition, is much more difficult to quantify, as both extensive screening among patients and HCWs and genotyping to demonstrate genetic similarities of MRSA isolates would be needed. Despite multiple, usually anecdotal, reports about MRSA carriage in HCWs, (as reviewed in [7
]), this parameter has to the best of our knowledge never been quantified.
Naturally, the relative effects of HCW decolonization depend on the parameters used in the model. For instance, at lower endemic levels of MRSA the effects of HCW decolonization would be relatively higher. However, the dependency of two parameters, the fraction persistently colonized HCWs and the percentage of acquisitions resulting from them, remains important in all settings and estimation of these parameters in clinical settings will allow more precise determination of the effectiveness of HCW decolonization in reducing nosocomial MRSA-transmission.
Several studies have attempted to quantify the effects of bacterial eradication therapies in hospitalized patients [22
]. In a systematic review, nasal application of mupirocin had, as compared to placebo, an estimated pooled relative risk of failure to eradicate nasal S. aureus
carriage after one week of 0.10 (0.07-0.14), and effects were similar for patients and healthy subjects as well as in studies including only MSSA or both MSSA and MRSA carriers [8
]. In a recent study, a combined approach of universal screening of MRSA carriage with PCR testing, followed by topical decolonization with mupirocin and isolation precautions for carriers, was associated with a 69.6% reduction in the aggregate hospital-associated MRSA disease incidence [24
]. However, in the latter study, as in most studies in the systematic review, several interventions were tested simultaneously, hampering accurate quantification of the effects of decolonization.
In a Spanish intensive care burn unit topical application of vancomycin in the nose, oropharynx and intestines was evaluated in an observational before-after study during nine years [25
]. Although no data are presented about the decolonization efficacy on a patient level, acquisition rates and average endemic patient prevalence levels were 80% lower with vancomycin use.
Another option, which we did not investigate, would be to restrict HCW decolonization to outbreak settings only. This strategy could lower the decolonization frequency of HCWs, especially when outbreaks are rare. However, the effectiveness of this strategy strongly depends on the definition of an outbreak and the sensitivity of detecting outbreaks.
Our analysis of non-instantaneous decolonization in the Additional file 1
is limited to patients. Indeed, instantaneous decolonization of HCWs may always be achieved in practice by temporary dismissal of known colonized HCWs and by replacing those by uncolonized ones.”
Although decolonization of patients seems, at least theoretically, an effective measure, these benefits should be balanced with potential adverse events. Topical use of mupirocin and antibiotics are considered safe, but selection of antibiotic resistance remains a potential threat. Especially the use of topical vancomycin should be carefully judged, as vancomycin is one the few remaining antibiotics available for intravenous treatment of MRSA infections.
Naturally, the model used is a simplification of reality. For instance, there are many specialized hospital wards with different patient populations and different patient transfer rates to other wards. Also, the susceptibility of patients to acquire MRSA will differ. Furthermore, we assumed that length of stay was not affected by colonization status, that all HCWs work in shifts of 8 hour, that direct transmission of MRSA between HCWs did not occur and that HCWs could not acquire persistent colonization outside hospital settings, e.g. from their colonized homes or families. Also, isolation was assumed to be equally efficacious in all isolated patients, which may not be true if the number of isolation beds available is limited. Finally, we did not explicitly model resistance development as a result of decolonization strategies. Our findings should, therefore, not be interpreted as a definitive argument in favour of widespread use of antibiotics for controlling the nosocomial spread of MRSA, but more as an illustration that different approaches might be more effective than our current strategies. Furthermore, we have identified research targets that could be pursued in epidemiological studies that are needed to further quantify the potential benefits of HCW decolonization.