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Targeted versus Universal Decolonization to Prevent ICU Infection
Susan S. Huang, M.D., M.P.H., Edward Septimus, M.D., Ken Kleinman, Sc.D.,
Julia Moody, M.S., Jason Hickok, M.B.A., R.N., Taliser R. Avery, M.S.,
Julie Lankiewicz, M.P.H., Adrijana Gombosev, B.S., Leah Terpstra, B.A.,
Fallon Hartford, M.S., Mary K. Hayden, M.D., John A. Jernigan, M.D.,
Robert A. Weinstein, M.D., Victoria J. Fraser, M.D., Katherine Haffenreffer, B.S.,
Eric Cui, B.S., Rebecca E. Kaganov, B.A., Karen Lolans, B.S.,
Jonathan B. Perlin, M.D., Ph.D., and Richard Platt, M.D.,
for the CDC Prevention Epicenters Program and the AHRQ DECIDE Network
and Healthcare-Associated Infections Program*
BACKGROUND
Both targeted decolonization and universal decolonization of patients in intensive
care units (ICUs) are candidate strategies to prevent health care–associated infections,
particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA).
METHODS
We conducted a pragmatic, cluster-randomized trial. Hospitals were randomly assigned
to one of three strategies, with all adult ICUs in a given hospital assigned to
the same strategy. Group 1 implemented MRSA screening and isolation; group 2,
targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers);
and group 3, universal decolonization (i.e., no screening, and decolonization of
all patients). Proportional-hazards models were used to assess differences in infection
reductions across the study groups, with clustering according to hospital.
RESULTS
A total of 43 hospitals (including 74 ICUs and 74,256 patients during the intervention
period) underwent randomization. In the intervention period versus the baseline
period, modeled hazard ratios for MRSA clinical isolates were 0.92 for screening
and isolation (crude rate, 3.2 vs. 3.4 isolates per 1000 days), 0.75 for targeted
decolonization (3.2 vs. 4.3 isolates per 1000 days), and 0.63 for universal decolonization
(2.1 vs. 3.4 isolates per 1000 days) (P = 0.01 for test of all groups being equal).
In the intervention versus baseline periods, hazard ratios for bloodstream infection
with any pathogen in the three groups were 0.99 (crude rate, 4.1 vs. 4.2 infections
per 1000 days), 0.78 (3.7 vs. 4.8 infections per 1000 days), and 0.56 (3.6 vs. 6.1 infections
per 1000 days), respectively (P<0.001 for test of all groups being equal). Universal
decolonization resulted in a significantly greater reduction in the rate of all
bloodstream infections than either targeted decolonization or screening and isolation.
One bloodstream infection was prevented per 54 patients who underwent decolonization.
The reductions in rates of MRSA bloodstream infection were similar to
those of all bloodstream infections, but the difference was not significant. Adverse
events, which occurred in 7 patients, were mild and related to chlorhexidine.
CONCLUSIONS
In routine ICU practice, universal decolonization was more effective than targeted
decolonization or screening and isolation in reducing rates of MRSA clinical isolates
and bloodstream infection from any pathogen. (Funded by the Agency for
Healthcare Research and the Centers for Disease Control and Prevention; REDUCE
MRSA ClinicalTrials.gov number, NCT00980980.)
NEJMoa1207290.pdf
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