MRSA Decolonization Warranted During Outbreak

DESTIN, FLA. – The prevention of recurrence in patients presenting with methicillin-resistant Staphylococcus aureus skin infections may require decolonization of certain skin surfaces, Dr. Dirk M. Elston said at a meeting sponsored by the Alabama Dermatology Society.

In fact, with MRSA outbreaks, the decolonization of carriers–who typically comprise at least a third, if not most, of the affected population–is warranted, he said.

Although most carriers will not become infected, there are no good data to help determine which individuals should or should not be treated. In cases of a neonatal ICU outbreak, for example, all of the babies might be colonized, and perhaps only one will become sick–but that one might die as a result.

Moist skin surfaces are typically the areas of concern. In addition to the nares, which are the most common areas for MRSA carriage, the axilla, groin, and perianal areas also are typical areas of carriage. The hands in patients with eczema or fissures, and areas such as legs that are shaved and develop folliculitis or have nicks also are high-risk areas and should be targeted for decolonization.

Oral and intravenous antibiotic treatments don't reach areas such as axillary and groin surface skin, so topical treatments typically are required to eradicate skin surface carriage in those areas, said Dr. Elston, director of the department of dermatology at Geisinger Medical Center, Danville, Pa.

Evidence-based recommendations on the best decolonization strategies are lacking, but there is evidence to support some approaches. In vitro data suggest that zinc may interfere with bacterial adherence, thus a product such as the ZNP bar–a soap containing 2% pyrithione zinc–may be helpful, but clinical studies of this approach are needed.

“Failing that, bleach baths are still great,” Dr. Elston said. Two tablespoons (about 2 capfuls) in a bathtub filled with water is sufficient. Up to 1/4 cup can be used, but skin peeling or irritation may occur at this dose. The optimal frequency for bleach bathing has not been established, however. Recommendations can range from weekly to daily. Products containing 10% benzoyl peroxide are another inexpensive alternative that can be used on the skin instead of bleach, he added.

Other topical products that may be useful for MRSA decolonization of the non-nares skin surface areas include chlorhexidine topical antiseptic (Hibiclens) and antibacterial products containing triclosan, which is found in a number of common products, Dr. Elston noted.

As for nares decolonization, mupirocin, which has long been used for this purpose, is losing efficacy because of increasing resistance. Published clearance rates are below 30%–not bad, but not great, he said, suggesting that another topical should be used as a replacement for mupirocin or in conjunction with it. Fusidic acid is one option, and among newer agents is retapamulin, which is expensive, but thus far, typical MRSA strains in the United States remain susceptible to this drug.

“This is probably better than mupirocin for the nose,” said Dr. Elston, noting that that MRSA decolonization of the nares is an off-label use for this drug.

Tea tree oil also appears to be an effective option for MRSA decolonization. Soaps and creams containing tea tree oil were shown in at least one study to be as effective as a number of antibiotic drug treatments for decolonization when used in the nares–at far less expense.

Research has shown that towels and bar soaps, which are frequently shared among children in families, and even among athletes in the locker room, are the most common sources of MRSA transmission, and sharing should be discouraged.

DESTIN, FLA. – The prevention of recurrence in patients presenting with methicillin-resistant Staphylococcus aureus skin infections may require decolonization of certain skin surfaces, Dr. Dirk M. Elston said at a meeting sponsored by the Alabama Dermatology Society.

In fact, with MRSA outbreaks, the decolonization of carriers–who typically comprise at least a third, if not most, of the affected population–is warranted, he said.

Although most carriers will not become infected, there are no good data to help determine which individuals should or should not be treated. In cases of a neonatal ICU outbreak, for example, all of the babies might be colonized, and perhaps only one will become sick–but that one might die as a result.

Moist skin surfaces are typically the areas of concern. In addition to the nares, which are the most common areas for MRSA carriage, the axilla, groin, and perianal areas also are typical areas of carriage. The hands in patients with eczema or fissures, and areas such as legs that are shaved and develop folliculitis or have nicks also are high-risk areas and should be targeted for decolonization.

Oral and intravenous antibiotic treatments don't reach areas such as axillary and groin surface skin, so topical treatments typically are required to eradicate skin surface carriage in those areas, said Dr. Elston, director of the department of dermatology at Geisinger Medical Center, Danville, Pa.

Evidence-based recommendations on the best decolonization strategies are lacking, but there is evidence to support some approaches. In vitro data suggest that zinc may interfere with bacterial adherence, thus a product such as the ZNP bar–a soap containing 2% pyrithione zinc–may be helpful, but clinical studies of this approach are needed.

“Failing that, bleach baths are still great,” Dr. Elston said. Two tablespoons (about 2 capfuls) in a bathtub filled with water is sufficient. Up to 1/4 cup can be used, but skin peeling or irritation may occur at this dose. The optimal frequency for bleach bathing has not been established, however. Recommendations can range from weekly to daily. Products containing 10% benzoyl peroxide are another inexpensive alternative that can be used on the skin instead of bleach, he added.

Other topical products that may be useful for MRSA decolonization of the non-nares skin surface areas include chlorhexidine topical antiseptic (Hibiclens) and antibacterial products containing triclosan, which is found in a number of common products, Dr. Elston noted.

As for nares decolonization, mupirocin, which has long been used for this purpose, is losing efficacy because of increasing resistance. Published clearance rates are below 30%–not bad, but not great, he said, suggesting that another topical should be used as a replacement for mupirocin or in conjunction with it. Fusidic acid is one option, and among newer agents is retapamulin, which is expensive, but thus far, typical MRSA strains in the United States remain susceptible to this drug.

“This is probably better than mupirocin for the nose,” said Dr. Elston, noting that that MRSA decolonization of the nares is an off-label use for this drug.

Tea tree oil also appears to be an effective option for MRSA decolonization. Soaps and creams containing tea tree oil were shown in at least one study to be as effective as a number of antibiotic drug treatments for decolonization when used in the nares–at far less expense.

Research has shown that towels and bar soaps, which are frequently shared among children in families, and even among athletes in the locker room, are the most common sources of MRSA transmission, and sharing should be discouraged.

DESTIN, FLA. – The prevention of recurrence in patients presenting with methicillin-resistant Staphylococcus aureus skin infections may require decolonization of certain skin surfaces, Dr. Dirk M. Elston said at a meeting sponsored by the Alabama Dermatology Society.

In fact, with MRSA outbreaks, the decolonization of carriers–who typically comprise at least a third, if not most, of the affected population–is warranted, he said.

Although most carriers will not become infected, there are no good data to help determine which individuals should or should not be treated. In cases of a neonatal ICU outbreak, for example, all of the babies might be colonized, and perhaps only one will become sick–but that one might die as a result.

Moist skin surfaces are typically the areas of concern. In addition to the nares, which are the most common areas for MRSA carriage, the axilla, groin, and perianal areas also are typical areas of carriage. The hands in patients with eczema or fissures, and areas such as legs that are shaved and develop folliculitis or have nicks also are high-risk areas and should be targeted for decolonization.

Oral and intravenous antibiotic treatments don't reach areas such as axillary and groin surface skin, so topical treatments typically are required to eradicate skin surface carriage in those areas, said Dr. Elston, director of the department of dermatology at Geisinger Medical Center, Danville, Pa.

Evidence-based recommendations on the best decolonization strategies are lacking, but there is evidence to support some approaches. In vitro data suggest that zinc may interfere with bacterial adherence, thus a product such as the ZNP bar–a soap containing 2% pyrithione zinc–may be helpful, but clinical studies of this approach are needed.

“Failing that, bleach baths are still great,” Dr. Elston said. Two tablespoons (about 2 capfuls) in a bathtub filled with water is sufficient. Up to 1/4 cup can be used, but skin peeling or irritation may occur at this dose. The optimal frequency for bleach bathing has not been established, however. Recommendations can range from weekly to daily. Products containing 10% benzoyl peroxide are another inexpensive alternative that can be used on the skin instead of bleach, he added.

Other topical products that may be useful for MRSA decolonization of the non-nares skin surface areas include chlorhexidine topical antiseptic (Hibiclens) and antibacterial products containing triclosan, which is found in a number of common products, Dr. Elston noted.

As for nares decolonization, mupirocin, which has long been used for this purpose, is losing efficacy because of increasing resistance. Published clearance rates are below 30%–not bad, but not great, he said, suggesting that another topical should be used as a replacement for mupirocin or in conjunction with it. Fusidic acid is one option, and among newer agents is retapamulin, which is expensive, but thus far, typical MRSA strains in the United States remain susceptible to this drug.

“This is probably better than mupirocin for the nose,” said Dr. Elston, noting that that MRSA decolonization of the nares is an off-label use for this drug.

Tea tree oil also appears to be an effective option for MRSA decolonization. Soaps and creams containing tea tree oil were shown in at least one study to be as effective as a number of antibiotic drug treatments for decolonization when used in the nares–at far less expense.

Research has shown that towels and bar soaps, which are frequently shared among children in families, and even among athletes in the locker room, are the most common sources of MRSA transmission, and sharing should be discouraged.