A randomized clinical trial found that nasal mupirocin is more effective than nasal iodophor for reducing Staphylococcus aureus and methicillin-resistant S aureus (MRSA) in intensive care unit (ICU) patients, researchers reported this week in JAMA.
In the cluster-randomized noninferiority trial, investigators randomized 801,668 ICU patients at 137 US hospitals to receive universal decolonization with nasal mupirocin (an antibiotic ointment) plus chlorhexidine gluconate (CHG) bathing or nasal iodophore (an antiseptic) plus CHG bathing.
While a trial conducted from 2009 to 2011 found that universal decolonization with mupirocin and CHG reduced MRSA clinical cultures by 37% and bloodstream infections by 44% in ICU patients, and CHG bathing has been broadly adopted in ICUs, there have been concerns that widespread use of mupirocin could promote resistance in S aureus. Iodophore is considered a potential alternative.
The investigators compared ICU-attributable S aureus cultures, MRSA clinical cultures, and all-cause bloodstream infections in the baseline period—when all hospitals used mupirocin-CHG for universal decolonization—and the intervention period. The noninferiority margin was 10%.
Iodophore inferior to mupirocin
When comparing the two periods, the relative hazard of S aureus clinical cultures was significantly higher by 18.4% for the iodophor-CHG group (hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.12 to 1.23) compared with the mupirocin-CHG group (HR, 0.99; 95% CI, 0.94 to 1.04).
Similarly, MRSA clinical cultures were significantly higher by 14.1% for iodophor-CHG compared with mupirocin-CHG (HR, 1.13 vs 0.99, respectively). For all-cause bloodstream infections, iodophore-CHG was not inferior to mupirocin-CHG (HR, 1.00 vs 1.01, respectively).
This large study confirms that clearing the nose of bacteria prevents infection, and that the choice of product matters.
In addition, when the investigators compared the results from the current trial to the 2009-2011 trial, they found that mupirocin-CHG decolonization remained as effective at reducing S aureus in ICU patients.
“This large study confirms that clearing the nose of bacteria prevents infection, and that the choice of product matters,” lead trial investigator Susan Huang, MD, MPH, of the University of California Irvine (UCI), said in a UCI Health press release. “Mupirocin antibiotic ointment remains the best treatment, and serious ICU infections can be avoided by simply giving patients mupirocin for the first five days of an ICU stay along with daily chlorhexidine bathing.”