Articles
Effect of body surface decolonisation on bacteriuria and candiduria in intensive care units: an analysis of a cluster-randomised trial

https://doi.org/10.1016/S1473-3099(15)00238-8Get rights and content

Summary

Background

Urinary tract infections (UTIs) are common health-care-associated infections. Bacteriuria commonly precedes UTI and is often treated with antibiotics, particularly in hospital intensive care units (ICUs). In 2013, a cluster-randomised trial (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) showed that body surface decolonisation reduced all-pathogen bloodstream infections. We aim to further assess the effect of decolonisation on bacteriuria and candiduria in patients admitted to ICUs.

Methods

We did a secondary analysis of a three-group, cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The three groups included were either meticillin-resistant Staphylococcus aureus (MRSA) screening and isolation, targeted decolonisation (screening, isolation, and decolonisation of MRSA carriers) with chlorhexidine and mupirocin, and universal decolonisation (no screening, all patients decolonised) with chlorhexidine and mupirocin. Protocol included chlorhexidine cleansing of the perineum and proximal 6 inches (15·24 cm) of urinary catheters. ICUs within the same hospital were assigned the same strategy. Outcomes included high-level bacteriuria (≥50 000 colony forming units [CFU]/mL) with any uropathogen, high-level candiduria (≥50 000 CFU/mL), and any bacteriuria with uropathogens. Sex-specific analyses were specified a priori. Proportional hazards models assessed differences in outcome reductions across groups, comparing an 18-month intervention period to a 12-month baseline period.

Findings

122 646 patients (48 390 baseline, 74 256 intervention) were enrolled. Intervention versus baseline hazard ratios (HRs) for high-level bacteriuria were 1·02 (95% CI 0·88–1·18) for screening or isolation, 0·88 (0·76–1·02) for targeted decolonisation, and 0·87 (0·77–1·00) for universal decolonisation (no difference between groups, p=0·26), with no sex-specific reductions (HRs for men: 1·09 [95% CI 0·85–1·40] for screening or isolation, 1·01 [0·79–1·29] for targeted decolonisation, and 0·78 [0·63–0·98] for universal decolonisation, p=0·12; HRs for women: 0·97 [0·80–1·17] for screening and isolation, 0·83 [0·70–1·00] for targeted decolonisation, and 0·93 [0·79–1·09] for universal decolonisation, p=0·49). HRs for high-level candiduria were 1·14 (0·95–1·37) for screening and isolation, 0·99 (0·83–1·18) for targeted decolonisation, and 0·83 (0·70–0·99) for universal decolonisation (p=0·05). Differences between sexes were due to reductions in men in the universal decolonisation group (HRs: 1·21 [95% CI 0·88–1·68] for screening or isolation, 1·01 [0·73–1·39] for targeted decolonisation, and 0·63 [0·45–0·89] for universal decolonisation, p=0·02). Bacteriuria with any CFU/mL was also reduced in men in the universal decolonisation group (HRs 1·01 [0·81–1·25] for screening or isolation, 1·04 [0·83–1·30] for targeted decolonisation, and 0·74 [0·61–0·90] for universal decolonisation, p=0·04).

Interpretation

Universal decolonisation of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin could be a potential preventive strategy in male patients because it significantly decreases candiduria and any bacteriuria, but not for women.

Funding

HAI Program from AHRQ, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, CDC Prevention Epicenters Program.

Introduction

Urinary tract infections (UTIs) are one of the most common hospital-associated infections with 93 000 annual cases reported in the USA, incurring an excess cost of US$900 per episode.1, 2 38% of these occur in the intensive care unit (ICU) where urinary catheters are commonly used.1

Risk factors for UTIs include female sex, aged 65 years or older, compromised immune system, and urinary catheters. Although prevention is needed for all-cause UTIs, prevention strategies have focused on catheter-associated UTIs that account for 80% of hospital-associated UTIs.3 Guidelines emphasise appropriate catheter indications, aseptic insertion, maintenance of a closed unobstructed drainage system, and timely removal.4 Body decolonisation, which could affect catheter-related and non-catheter related UTIs, has not been explored in large-scale studies.

UTIs in the ICU setting are difficult to diagnose because patients are often sedated and unable to verbalise symptoms such as dysuria, urinary frequency, or urgency. Thus, these symptoms are poor predictors of UTI in the ICU setting.5 Because of this difficulty, many studies have used colony count thresholds in urinary cultures to suggest UTI for known uropathogens.6, 7, 8 Even though this measure probably shows a mixture of UTIs and asymptomatic bacteriuria, this approach allows a pragmatic and objective definition that correlates with antibiotic treatment by clinicians.9

In 2013, a large cluster-randomised trial of hospitals (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) reported that universal decolonisation of adult ICU patients with a chlorhexidine bath every day and a short course of mupirocin nasal ointment resulted in a reduction in both meticillin-resistant Staphylococcus aureus (MRSA) clinical cultures and all pathogen bloodstream infections.10 We aim to assess the effect of the three REDUCE MRSA Trial interventions on bacteriuria and candiduria in patients in hospital ICUs.

Section snippets

Study design and participants

We did a secondary analysis of the REDUCE MRSA trial, a cluster-randomised trial of 43 hospitals (clusters; 74 adult ICUs) in the USA assigned to three MRSA prevention strategies. Patients admitted to participating hospital ICUs during baseline and intervention periods were included in the REDUCE MRSA study; we used these patient data. The trial included a 12-month baseline period from Jan 1, 2009, to Dec 31, 2009, a phase-in period from Jan 1, 2010, to April 7, 2010, and an 18-month

Results

From June 24, 2009, to Dec 10, 2009, 55 hospitals were screened and recruited and from this total, 45 (82%) hospitals were enrolled into the REDUCE MRSA trial (figure 1). 45 hospitals (78 adult ICUs) in 16 states were randomly assigned to one of three different prevention strategies for MRSA (figure 1). 43 hospitals (74 ICUs) initiated the assigned intervention; but two hospitals (four ICUs) randomly assigned were excluded from analyses because they met pre-existing exclusion criteria, which

Discussion

Our findings suggest that universal decolonisation could be a potentially new and effective strategy for the prevention of overall bacteriuria and high-level candiduria in only male ICU patients (panel).

Despite established guidance for UTI prevention,15, 16 data show that UTIs have not abated.24, 25 In fact, the USA reported a slight rise in UTIs between 2009 and 2012.25 Thus, advancements in effective UTI prevention strategies are needed.

Although the decolonisation intervention included both

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