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Surgical site infections (SSIs) are the most common and costly of all hospital-acquired infections, occurring in 5 percent of patients and accounting for 20% of all hospital-acquired infections. Preoperatively, we developed a protocol where patients were screened using hemoglobin A 1c (HbA1c) and nasal swabs. If HbA1c was greater than 9, patients were rescheduled for surgery when their HbA1c was less than 9. All patients then underwent nasal swabs to identify methicillin-sensitive Staphylococcus aureus/methicillin-resistant S. aureus in addition to standard chlorhexidine gluconate bathing. If positive, mupirocin ointment was used to treat the patients 5 days prior to surgery. We sought to measure the effectiveness of this protocol in reducing SSI in elective neurosurgical patients who were undergoing hardware implantation or had a procedure anticipated to last greater than 2 hours.This was a retrospective review of patients undergoing elective neurosurgical procedures at Conemaugh Memorial Medical Center from 1/1/2014 to 06/30/2016. The intervention period was from 7/1/2016 to 12/20/2018, which included the patients undergoing the protocol.The preintervention group consisted of 817 cases with a 2.7% infection rate (22 SSIs). The intervention group consisted of 822 cases with a 0.1% infection rate (1 SSI). This observed difference was statistically significant (P = 0.003).This retrospective review of a presurgical protocol with measuring of HbA1c and nasal swabs revealed a significant decrease in the infection rate of patients undergoing elective neurosurgical procedures. Additional investigations are necessary; however, we recommend its use.

Background The CLEAR Trial demonstrated that a multisite body decolonization regimen reduced post-discharge infection and hospitalization in methicillin-resistant Staphylococcus aureus (MRSA) carriers. Here, we describe decolonization efficacy. Methods We performed a large, multicenter, randomized clinical trial of MRSA decolonization among adult patients after hospital discharge with MRSA infection or colonization. Participants were randomized 1:1 to either MRSA prevention education or education plus decolonization with topical chlorhexidine, oral chlorhexidine, and nasal mupirocin. Participants were swabbed in the nares, throat, axilla/groin, and wound (if applicable) at baseline and 1, 3, 6, and 9 months after randomization. The primary outcomes of this study are follow-up colonization differences between groups. Results Among 2121 participants, 1058 were randomized to decolonization. By 1 month, MRSA colonization was lower in the decolonization group compared with the education-only group (odds ration [OR] = 0.44; 95% confidence interval [CI], .36–.54; P ≤ .001). A similar magnitude of reduction was seen in the nares (OR = 0.34; 95% CI, .27–.42; P < .001), throat (OR = 0.55; 95% CI, .42–.73; P < .001), and axilla/groin (OR = 0.57; 95% CI, .43–.75; P < .001). These differences persisted through month 9 except at the wound site, which had a relatively small sample size. Higher regimen adherence was associated with lower MRSA colonization (P ≤ .01). Conclusions In a randomized, clinical trial, a repeated post-discharge decolonization regimen for MRSA carriers reduced MRSA colonization overall and at multiple body sites. Higher treatment adherence was associated with greater reductions in MRSA colonization.

A burn is one of the most difficult injuries people can face.The primary pathology is coagulation necrosis resulting from tissue damage.Many wound care products have been developed to be used in situations such as the poor general condition of the patient and lack of solid area to be grafted. However, the high costs of these products make their use complicated.In this study, the effect of PEMF on cutaneous wound healing in an animal burn model was evaluated and the dose and duration of the magnetic field should be discussed for this effect to occur. Animals were divided into five groups including eight each (n = 40) (Groups 1, 2, 3, 4, 5).Group 1 was the control group; received no treatment after second-degree burn wound. Group 2 received daily wound care with saline. Group 3 received daily wound care with pomade containing mupirocin. Group 4 received Pulsed Electromagnetic Field signal for 60 min (1.5 m T and 40 Hz for seven days and Group 5 also received PEMF signal for 60 min the same frequency and intensity for14 days. Microscopically, second-degree burn wounds were successfully detected in all rats. Histopathological examination results in no significant difference between groups in neutrophil infiltration. The difference between the groups in vascularization was statistically significant between Group II and Group V (p < 0.001) and between Group I and Group V (p = 0.005) Epithelialization was present in 75% of the rats in Group V, while no epithelialization was observed in any of the other groups. In conclusion, we observed a significant improvement in the stasis zone of the group receiving Pulsed Electromagnetic Field for two weeks.

Structured Summary Background To prevent transmission of and infection with meticillin-resistant Staphylococcus aureus (MRSA), eradication treatment of colonized individuals is recommended. Throat colonization is a well-known risk factor for eradication failure. Staphylococcus aureus throat colonization is associated with colonization of the rhinopharynx, but in the currently recommended Danish MRSA eradication strategies, rhinopharynx colonization is not directly targeted. Rhinopharynx colonization could therefore be an important risk factor for prolonged MRSA throat carriage. Aim To determine if irrigation and wash of the rhinopharynx and mouth with dissolved mupirocin is a feasible and potentially efficacious supplementary strategy against treatment resistant MRSA throat carriage. Methods The patient study was an open, non-blinded, trial including 20 treatment resistant MRSA throat carriers. In the study, the patients received a supplementary treatment besides the standard treatment according to the Danish MRSA eradication strategy. The supplementary treatment consisted of rhinopharyngeal irrigation and mouth gurgling twice a day for 14 days with a mupirocin ointment (22 g 2% ointment per liter of isotonic sterile saline solution) in a 37oC solution. Findings Eighteen patients (90%) complied with the treatment protocol and none experienced any major adverse events. Out of the 18 patients who finished the study per protocol, 15 (83%) and 7 (39%) patients had negative MRSA sampling results one and six months after end of treatment, respectively. Conclusions This study demonstrates the feasibility and clinical potential of also targeting the rhinopharynx and oropharynx in non-systemic throat MRSA eradication strategies.

Multidrug-resistant (MDR) Staphylococcus aureus biofilms have emerged as a serious threat to human health. Recently, the development of antibiotic replacement therapy has gained much attention due to the potential application of bacteriocin. The present study sought to evaluate the antibacterial effect of bacteriocin XJS01 against MDR S. aureus, a previously reported bacteriocin against S. aureus strain 2612:1606BL1486 (S. aureus_26, an MDR strain demonstrated here), and its potential application as an antibiofilm agent. The minimum bactericide concentration of XJS01 against MDR S. aureus_26 was 33.18 μg/mL. XJS01 exhibited excellent storage stability and resistance against acid and reduced the density of established MDR S. aureus_26 biofilm. The hemolytic and HEK293T cytotoxicity activities of XJS01 and the histological analyses in mice confirmed its safety. Moreover, XJS01 effectively disrupted the MDR S. aureus_26 biofilm established on the skin wound surface and reduced the biofilm-isolated bacteria, thereby decreasing the release of pro-inflammatory cytokines and the proliferation of alternatively activated macrophages. Compared to mupirocin, XJS01 exhibited an excellent therapeutic effect on mice skin wounds, confirming it to be a potential alternative to antibiotics.

Infections due to methicillin-resistant Staphylococcus aureus (MRSA) are a growing concern for public health resulting in increase in morbidity, length of hospital stay, and cost of treatment. MRSA nasal swab screening may give clinicians additional information for decision of empiric antimicrobial agents. While increasing antibiotic resistance leads to new treatment approaches, bacteriophages are one of the most promising methods for these alternatives. It was aimed to determine the effectiveness of bacteriophages against MRSA isolates. Nasal swab samples were collected from outpatients without any evidence of infection who applied to Hatay, Mersin and Gaziantep family and immigration health centers. A series (35) were isolated from Turkish patients, and G series (64) were isolated from Syrian immigrants. Methicillin resistance was determined phenotypically and genotypically. Also, antibiotic susceptibilities of all isolates were determined against erythromycin, clindamycin, gentamicin, linezolid, rifampicin, and mupirocin. The total antimicrobial resistance rates of isolates were found to be 11%, 28%, 8%, 5%, 16%, 19%, and 29% respectively. The high susceptibility rate against ciprofloxacin (88.8%) was remarkable. The overall susceptibility of MRSA strains to ENKO, INTESTI, PYO, SES, and staphylococcal bacteriophages was 67.7%, 55.5%, 53.5%, 61.6% and 44.4%, respectively. The antibiotic susceptibility rates (except erythromycin) and efficacy of bacteriophages were higher in group A. Considering that high efficacy rates were not achieved in the study and the sensitivity rates of Turkish isolates to all phages were found to be higher than those of Syrian isolates, searching for phages in the geographic regions where the pathogen is common may be helpful to obtain suitable phages for treatment.

Background Australian residential aged care facilities (RACFs) are encouraged to participate in an annual Aged Care National Antimicrobial Prescribing Survey. This data source was analysed to describe patterns of topical antimicrobial prescribing and thereby provide insight into antimicrobial stewardship (AMS) changes that might be required. Methods 2018 and 2019 survey data was analysed. Results The overall prevalence of the 52,431 audited residents (629 facilities) who were prescribed 1 or more topical antimicrobials was 2.9%. Of all prescribed antimicrobials (n=4899), 33.0% were for topical application. Most frequently prescribed topical antifungals were clotrimazole (85.3%) and miconazole (9.1%), and antibacterials chloramphenicol (64.1%) and mupirocin (21.8%). Tinea (38.3%) and conjunctivitis (23.8%) were the 2 most common indications. Topical antimicrobials were sometimes prescribed for pro re nata administration (38.8%) and greater than 6 months (11.3%). The review or stop date was not always documented (38.7%). Conclusions To reduce the possibility of adverse consequences associated with antimicrobial use, antimicrobial stewardship programs in Australian residential aged care facilities should at least ensure mupirocin is appropriately used, first line antimicrobial therapy is prescribed for tinea, chloramphenicol is prescribed for conjunctivitis only if necessary, pro re nata orders for prescriptions are discouraged and to avoid prolonged duration of prescriptions, review or stop dates are always documented.

Background The Isoleucyl-tRNA synthetase (IARS) catalyzes isoleucine to the corresponding tRNA, maintaining the accuracy of gene translation. Its role in psoriasis has been not investigated so far. In this study, we aimed to investigate the mechanisms underlying the efficacy of IARS inhibitor, mupirocin, treatment for psoriasis. Methods The expression of IARS was determined by immunofluorescence, Western blot and qRT-PCR in normal healthy control- and psoriatic human skin. An imiquimod (IMQ) -induced psoriasis-like skin disease model was used to study the phenotypes changed by an IARS inhibitor, mupirocin (MUP). Endotypes were analyzed by RNA-seq, R&D Luminex multi-factor technique, ELISA, immunofluorescence and flow cytometry. Additionally, the effect of MUP on epidermal keratinocytes (KCs) were conducted in-vitro in primary cultured human KCs. Results We found the expression of IARS was higher in psoriatic skin than in healthy controls. In IMQ-induced psoriasis-like C57BL/6 J mouse model, MUP reversed IMQ-induced keratinocytes proliferation, expression of inflammatory cytokines and infiltration of immune cells. Furthermore, in cultured human keratinocytes, MUP inhibited proliferation, but promoted apoptosis, which may be related with STAT3 signaling pathway. Conclusion Our finding of blocking the infiltration of immune cells by inhibiting the formation of IARS, could be one mechanism to explain the effect of MUP in the treatment of psoriasis. Developing strategies targeting suppression IARS should open new perspectives for the treatment of psoriasis. Graphical Abstract

Background: Nasal decolonization procedures against the opportunistic pathogen Staphylococcus aureus rely on topical antimicrobial drug usage, whose impact on the nasal microbiota is poorly understood. We examined this impact in healthy S. aureus carriers and noncarriers.Methods: This is a prospective interventional cohort study of 8 S. aureus carriers and 8 noncarriers treated with nasal mupirocin and chlorhexidine baths. Sequential nasal swabs were taken over 6 months. S. aureus was detected by quantitative culture and genotyped using spa typing. RNA-based 16S species-level metabarcoding was used to assess the living microbial diversity.Results: The species Dolosigranulum pigrum, Moraxella nonliquefaciens and Corynebacterium propinquum correlated negatively with S. aureus carriage. Mupirocin treatment effectively eliminated S. aureus, D. pigrum and M. nonliquefaciens, but not corynebacteria. S. aureus recolonization in carriers occurred more rapidly than recolonization by the dominant species in noncarriers (median 3 vs. 6 months, respectively). Recolonizing S. aureus isolates had the same spa type as the initial isolate. Conclusions: Mupirocin-chlorhexidine treatment had a long-lasting impact on the nasal microbiota. S. aureus recolonization predated microbiota recovery, emphasizing the strong adaptation of this pathogen to the nasal niche and the transient efficacy of the decolonization procedure.

Antimicrobial resistance is a major public health threat, and there is an urgent need for new strategies to address this issue. In a recent study, a library screening strategy was developed in which an FDA-approved drug library was screened against methicillin-resistant Staphylococcus aureus (MRSA) in both its original (unmetabolized [UM]) and its human liver microsome metabolized (postmetabolized [PM]) forms and in the absence and presence of a resistant-to antibiotic. This allows the identification of agents with active metabolites and agents that can act synergistically with the resistant-to antibiotic. In this study, this strategy is applied to VanA-type vancomycin-resistant Enterococcus faecium (VREfm) in the absence and presence of vancomycin. Thirteen drugs with minimum MICs that were ≤12.5 μM under any tested condition (UM/PM vs. -/+vancomycin) were identified. Seven of these appeared to act synergistically with vancomycin, and follow-up checkerboard analyses confirmed synergy (∑FICmin ≤0.5) for six of these. Ultimately four rifamycins, two pleuromutilins, mupirocin, and linezolid were confirmed as synergistic. The most synergistic agent was rifabutin (∑FICmin = 0.19). Linezolid, a protein biosynthesis inhibitor, demonstrated relatively weak synergy (∑FICmin = 0.5). Only mupirocin showed significantly improved activity after microsomal metabolism, indicative of a more active metabolite, but efforts to identify an active metabolite were unsuccessful. Spectra of activity of several hits and related agents were also determined. Gemcitabine showed activity against a number vancomycin-resistant E. faecium and E. faecalis strains, but this activity was substantially weaker than previously observed in MRSA.

BACKGROUND: Staphylococcus aureus (S. aureus) is the most common cause of surgical site infections, and the nose is the most common site for S. aureus colonization. Pre-surgical (in the days prior to surgery) nasal decolonization of S. aureus may reduce the bacterial load and prevent the organisms from being transferred to the surgical site, thus reducing the risk of surgical site infection. We conducted a health technology assessment of nasal decolonization of S. aureus (including methicillin-susceptible and methicillin-resistant strains) with or without topical antiseptic body wash to prevent surgical site infection in patients undergoing scheduled surgery, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding nasal decolonization of S. aureus, and patient preferences and values. METHODS: We performed a systematic literature search of the clinical evidence to retrieve systematic reviews and selected and reported results from one review that was recent, of high quality, and relevant to our research question. We complemented the chosen systematic review with a literature search to identify randomized controlled trials published since the systematic review was published in 2019. We used the Risk of Bias in Systematic Reviews (ROBIS) tool to assess the risk of bias of each included systematic review and the Cochrane risk-of-bias tool for randomized controlled trials to assess the risk of bias of each included primary study. We assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted both cost-effectiveness and cost-utility analyses using a decision-tree model with a 1-year time horizon from the perspective of Ontario's Ministry of Health. We also analyzed the budget impact of publicly funding nasal decolonization of S. aureus in pre-surgical patients in Ontario. To contextualize the potential value of nasal decolonization, we spoke with people who had recently undergone surgery, some of whom had received nasal decolonization, and one family member of a person who had recently had surgery. We also engaged participants through an online survey. RESULTS: We included one systematic review and three randomized controlled trials in the clinical evidence review. In universal decolonization, compared with placebo or no intervention, nasal mupirocin alone may result in little to no difference in the incidence of overall and S. aureus-related surgical site infections in pre-surgical patients undergoing orthopaedic, cardiothoracic, general, oncologic, gynaecologic, neurologic, or abdominal digestive surgeries, regardless of S. aureus carrier status (GRADE: Moderate to Very low). Compared with placebo, nasal mupirocin alone may result in little to no difference in the incidence of overall and S. aureus-related surgical site infections in pre-surgical patients who are S. aureus carriers undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, general, oncologic, gynaecologic, or neurologic surgery (GRADE: Moderate to Very low). In targeted decolonization, compared with placebo, nasal mupirocin combined with chlorhexidine body wash lowers the incidence of S. aureus-related surgical site infection (risk ratio: 0.32 [95% confidence interval: 0.16–0.62]) in pre-surgical patients who are S. aureus carriers undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, or general surgery (GRADE: High). Compared with no intervention, nasal mupirocin combined with chlorhexidine body wash in pre-surgical patients who are not S. aureus carriers undergoing orthopaedic surgery may have little to no effect on overall surgical site infection, but the evidence is very uncertain (GRADE: Very low). Most included studies did not separate methicillin-susceptible and methicillin-resistant strains of S. aureus. No significant antimicrobial resistance was identified in the evidence reviewed; however, the existing literature was not adequately powered and did not have sufficient follow-up time to evaluate antimicrobial resistance. Our economic evaluation found that universal nasal decolonization using mupirocin combined with chlorhexidine body wash is less costly and more effective than both targeted and no nasal decolonization. Compared with no nasal decolonization treatment, universal and targeted nasal decolonization using mupirocin combined with chlorhexidine body wash would prevent 32 and 22 S. aureus-related surgical site infections, respectively, per 10,000 patients. Universal nasal decolonization would lead to cost savings, whereas targeted nasal decolonization would increase the overall cost for the health care system since patients must first be screened for S. aureus carrier status before receiving nasal decolonization with mupirocin. The annual budget impact of publicly funding universal nasal decolonization in Ontario over the next 5 years ranges from a savings of $2.98 million in year 1 to a savings of $15.09 million in year 5. The annual budget impact of publicly funding targeted nasal decolonization ranges from an additional cost of $0.08 million in year 1 to an additional cost of $0.39 million in year 5. Our interview and survey respondents felt strongly about the value of preventing surgical site infections, and most favoured a universal approach. CONCLUSIONS: Based on the best evidence available, decolonization of S. aureus using nasal mupirocin combined with chlorhexidine body wash prior to cardiothoracic, vascular, orthopaedic, gastrointestinal, or general surgery lowers the incidence of surgical site infection caused by S. aureus in patients who are S. aureus carriers (including methicillin-susceptible and methicillin-resistant strains) (i.e., targeted decolonization). However, nasal mupirocin alone may result in little to no difference in overall surgical site infections and S. aureus-related surgical site infections in pre-surgical patients prior to orthopaedic, cardiothoracic, general, oncologic, gynaecologic, neurologic, or abdominal digestive surgeries, regardless of their S. aureus carrier status (i.e., universal decolonization). No significant antimicrobial resistance was identified in the evidence reviewed. Compared with no nasal decolonization treatment, universal nasal decolonization with mupirocin combined with chlorhexidine body wash may reduce S. aureus-related surgical site infections and lead to cost savings. Targeted nasal decolonization with mupirocin combined with chlorhexidine body wash may also reduce S. aureus-related surgical site infections but increase the overall cost of treatment for the health care system. We estimate that publicly funding universal nasal decolonization using mupirocin combined with chlorhexidine body wash would result in a total cost savings of $45.08 million over the next 5 years, whereas publicly funding targeted nasal decolonization using mupirocin combined with chlorhexidine body wash would incur an additional cost of $1.17 million over the next 5 years. People undergoing surgery value treatments aimed at preventing surgical site infections.

Objectives Skin and soft tissue infections commonly affect athletes and can lead to cluster outbreaks if not managed appropriately. We report the findings of an investigation into an outbreak of community-acquired Staphylococcus aureus infection in an Australian professional football team. Design Retrospective cross-sectional study. Methods Nose, axilla, groin and throat swab were collected from 47 participants. MRSA and MSSA isolates underwent antibiotic susceptibility testing, binary typing and whole genome sequencing. Infection control practitioners (ICPs) investigated the training grounds for risk factors in the transmission of S. aureus. Results Almost half of the participants (n = 23, 48.9%) were found to be colonised with MSSA. An outbreak cluster of MRSA ST5 closely related to the fusidic acid-resistant New Zealand NZAK3 clone was identified in a group of four players. MSSA ST15 and MSSA ST291 strains were found to have colonised and spread between two and five players, respectively. All participants were advised to undergo decolonisation treatment consisting of 4% chlorhexidine body wash and mupirocin nasal ointment for ten days. The ICP team identified several unhygienic practices within the club’s shared facilities that may have played a role in the transmission of S. aureus. Conclusions We report for the first time a community-associated S. aureus outbreak involving the highly successful fusidic acid-resistant MRSA ST5 clone in a professional football club associated with inadequate hygiene procedures. Management and prevention of S. aureus relies heavily on hygiene education and adherence to personal and environmental hygiene practices and policies.

Background Peritonitis is one of the major complications of peritoneal dialysis. The most common cause of peritonitis is infection at the catheter exit site. This study aimed to determine the effect of propolis on the incidence of catheter exit site infection and peritonitis in peritoneal dialysis patients. Method This study was a double-blind clinical trial (2019–2020) with peritoneal dialysis patients. Ninety peritoneal dialysis patients were allocated to three groups (placebo, control, intervention) using block randomization method. Catheter exit site was washed with 0.9% normal saline and dressing was done every other day after the morning peritoneal dialysis exchange by use of normal saline in placebo, mupirocin in control, and propolis in intervention group, for 6 months. Discussion 10% of the patients in the placebo and 6.7% in the control group developed catheter Exit Site Infection, but none patient in the intervention group developed this infection (P = 0.469). Whereas 6.7% in both the placebo and control groups developed peritonitis, but none patient in the intervention group contracted peritonitis (P = 0.997). No significant differences in the incidence of catheter exit site infection and peritonitis among the three groups were observed. Considering that mupirocin is of chemical origin and may lead to drug resistance whereas propolis is of plant origin and does not produce drug resistance, the use of propolis is recommended. Trial registration Iranian Registry of Clinical Trials [IRCT20110427006318N10] (17/01/2019).

Background Staphylococcus aureus is a frequent colonizer of the human skin and mucous membranes but can also cause a variety of serious infections. Antimicrobial resistance is an increasing worldwide challenge and is mainly driven by an overuse of antimicrobials. To avoid the spread of methicillin-resistant Staphylococcus aureus (MRSA) in Denmark, the Danish Health Authority recommends decolonization treatment of MRSA carriers and their household contacts. Standard decolonization treatment includes chlorhexidine body wash and mupirocin nasal ointment, especially throat carriage is difficult to treat. The broad-spectrum antibiotic, clindamycin, is often added to the decolonization treatment, but there is currently low scientific evidence for this treatment. Aim To investigate whether the addition of clindamycin to the standard decolonization treatment increases decolonization success in MRSA throat carriers. Methods A randomized, placebo-controlled, double-blinded trial, including patients ≥ 18 years, who tested MRSA positive in the throat after completing one standard decolonization treatment. All carriers included in the trial receive standard decolonization treatment and are randomized to treatment with either placebo or clindamycin capsules for 10 days. We plan to include 40 participants in each of the two treatment arms. Discussion Due to the lack of consistent scientific evidence of clindamycin’s effect in MRSA decolonization and the worldwide urgent need to reduce the use of antibiotics, we judged that a 30% increase in the decolonization success rate in carriers treated with clindamycin is appropriate to justify prescribing clindamycin as part of the decolonization treatment of asymptomatic MRSA carriers. Trial registration EudraCT number 2019-002631-29

Methicillin-resistant

Background Nasal carriers of Staphylococcus aureus are at increased risk of postoperative surgical site infection. Nasal decolonization with mupirocin is recommended in patients undergoing cardiac surgery to reduce surgical site infection. These data are still lacking in Thailand. Therefore, the aim of this study was to determine the prevalence of S. aureus nasal carriage in Thai patients undergoing elective cardiac surgery. The association of surgical site infection and S. aureus nasal carriage was also examined. Methods This was a prospective cohort study of 352 patients who planned to undergo elective cardiac surgery. Nasal swab culture was performed in all patients preoperatively. Results Of 352 patients, 46 (13.1%) had a positive nasal swab culture for methicillin-sensitive S. aureus (MSSA) and one patient (0.3%) harbored a methicillin-resistant S. aureus (MRSA) strain. The incidence of superficial and deep surgical site infection was 1.3% and 0.3%, respectively. After multivariate analysis, S. aureus nasal carriage was independently associated with superficial surgical site infection (odds ratio 13.04, 95% confidence interval 1.28–133.27; P = 0.03). Conclusions The prevalence of MSSA and MRSA nasal carriage in Thai patients undergoing elective cardiac surgery was low. The incidence of surgical site infection was also very low in the population studied. Nevertheless, it was found that S. aureus nasal carriage increased the risk of superficial surgical site infection.

Impetigo is a superficial bacterial skin infection largely affecting the pediatric population. The objective of this review is to provide a comparison of mechanism of action, efficacy and safety of the available topical antibiotics for impetigo.Randomized clinical trials that evaluated the use of topical antibiotics for treatment of impetigo were included. Two thousand eighty-nine studies were initially identified, and five randomized clinical trials met the criteria for further analysis.Topical antibiotics had greater resolution of impetigo in comparison to vehicle in these pivotal clinical trials. Adverse events were minimal, with the most common being pruritus at the application site. Cost or insurance coverage may be a limiting factor in choosing the best therapeutic agent, with mupirocin ointment having the lowest cost. Mupirocin has shown clinical efficacy against MRSA but a bacterial culture is recommended to rule out resistance. Ozenoxacin and retapamulin are effective alternatives but may entail higher cost. Retapamulin is indicated for lesions of impetigo that are colonized by MSSA and streptococcus S. pyogenes but not MRSA based on clinical efficacy of phase III trials. Fusidic acid, available in other countries, is a non-FDA approved medication although rising resistance rates represent a growing concern.

BACKGROUND/AIM We created a novel, preoperative wellness program (WP) that promotes recovery. This study assessed its impact on patient outcomes after pancreatectomy. PATIENTS AND METHODS Pancreatoduodenectomies (PD) and distal pancreatectomies (DP) performed from 2015 to 2018 were reviewed using our institutional NSQIP database. Patients in the WP had their medical conditions optimized and were provided with the following: chlorhexidine, topical mupirocin, incentive spirometer, and immune-nutrition supplements. RESULTS Out of a total of 669 pancreatectomy patients (411 PD, 258 DP), 308 were enrolled in the WP (188 PD, 120 DP). In the PD subgroup, on multivariable analysis (MVA), the WP patients had shorter lengths of hospital stay (LOS) (12 vs. 10 days, p

Background Although presurgical nasal decontamination with mupirocin (NDM) has been advocated as a measure for preventing postsurgical mediastinitis (PSM) due to Staphylococcus aureus, this strategy is not universally recommended due to lack of robust supporting evidence. We aimed to evaluate the role of preoperative NDM in the annual incidence of S. aureus PSM at our institution. Methods An interrupted time-series analysis, with an autoregressive error model, was applied to our single-center cohort by comparing preintervention (1990–2003) and postintervention (2005–2018) periods. Logistic regression was performed to analyze risk factors for S. aureus PSM. Results 12 236 sternotomy procedures were analyzed (6370 [52.1%] and 5866 [47.9%] in the pre- and postintervention periods, respectively). The mean annual percentage adherence to NDM estimated over the postintervention period was 90.2%. Only 4 of 127 total cases of S. aureus PSM occurred during the 14-year postintervention period (0.68/1000 sternotomies vs 19.31/1000 in the preintervention period; P Conclusions Our experience suggests the implementation of preoperative NDM significantly reduces the incidence of S. aureus PSM.

Impetigo, a highly contagious bacterial skin infection commonly occurring in young children, but adults may also be affected. The superficial skin infection is mainly caused by Staphylococcus aureus (S. aureus) and less frequently by Streptococcus pyogenes (S. pyogenes). Antimicrobial resistance has become a worldwide concern and needs to be addressed when selecting treatment for impetigo patients. An evidence-based impetigo treatment algorithm was developed to address the treatment of impetigo for pediatric and adult populations.An international panel of pediatric dermatologists, dermatologists, pediatricians, and pediatric infectious disease specialists employed a modified Delphi technique to develop the impetigo treatment algorithm. Treatment recommendations were evidence-based, taking into account antimicrobial stewardship and the increasing resistance to oral and topical antibiotics.The algorithm includes education and prevention of impetigo, diagnosis and classification, treatment measures, and follow-up and distinguishes between localized and widespread or epidemic outbreaks of impetigo. The panel adopted the definition of localized impetigo of fewer than ten lesions and smaller than 36 cm2 area affected in patients of two months and up with no compromised immune status. Resistance to oral and topical antibiotics prescribed for the treatment of impetigo such as mupirocin, retapamulin, fusidic acid, have been widely reported.When prescribing antibiotics, it is essential to know the local trends in antibiotic resistance. Ozenoxacin cream 1% is highly effective against S. pyogenes and S. aureus, including methycyllin-susceptible and resistant strains (MRSA), and may be a suitable option for localized impetigo.J Drugs Dermatol. 2021;20(2):134-142. doi:10.36849/JDD.5475 THIS ARTICLE HAD BEEN MADE AVAILABLE FREE OF CHARGE. PLEASE SCROLL DOWN TO ACCESS THE FULL TEXT OF THIS ARTICLE WITHOUT LOGGING IN. NO PURCHASE NECESSARY. PLEASE CONTACT THE PUBLISHER WITH ANY QUESTIONS.

Aim:: To design controlled release topical delivery of mupirocin for the treatment of skin infection. Background:: Mupirocin is an antibacterial drug. Mupirocin works to kill the bacteria, which include strains of Staphylococcus aureus and Streptococcus pyogenes. It is also used for the treatment of inflammation of a hair follicle. The half-life of mupirocin is only 20-40 min. It has very slight solubility in water. Patent literature had shown work on ointment, antibiotic composition, nasal and topical composition. Emulgel is a duel control release system for the topical delivery of hydrophobic drugs. Objective:: The objective was to formulate emulgel with controlled delivery of mupirocin using Sepineo P 600. Methods:: Soya oil, tween 80 and polyethylene glycol 400 (Oil:Surfactant:Cosurfactant) were used for emulsion formulation. Emulgel was optimized by 32 factorial design. Sepineo P 600 and hydroxy propyl methyl cellulose K4M were used as independent variables. Drug excipient compatibility analysis was carried out by FTIR, UV and DSC spectra. Emulgel was evaluated for its physical characterization, in vitro release, ex vivo release, antimicrobial and anti-inflammatory study. Results:: DSC, UV and FTIR analysis confirmed drug excipient compatibility. FE SEM showed a size range between 228-255 nm. Zeta potential was found to be -25.1 mV, which showed good stability of the emulsion. Design expert software showed F2 as an optimized batch. Release studies indicated that the controlled release of drugs forms Sepineo P 600 gel due to its higher gelling capacity. Batch F2 showed comparable results with marketed formulation against Staphylococcus aureus. For batch F2, 40 μg/ml was the minimal inhibitory concentration. Conclusion:: Antimicrobial and anti-inflammatory study proved successful development of stably controlled release mupirocin emulgel.

Preoperative decolonization, especially of Staphylococcus aureus carriers, has been proposed to reduce periprosthetic joint infections (PJI), but the evidence-based consensus is still lacking and data on long-term outcomes is scarce. In a previous randomized, single-blinded trial, decolonization produced no significant reduction of surgical site infections in overall elective orthopedic surgery at 3-month follow-up. A 2-year follow-up was then performed to specifically detect the impact of decolonization on delayed-onset PJI (3-24 months after surgery). Between November 2015 and September 2017, 613 of 1318 recruited patients underwent prosthetic surgery. Individuals were allocated into either the S. aureus carrier group (34%, 207 of 613 patients) or the noncarrier group (406 of 613 patients), according to nasal swab screening results. Both groups were then randomized into intervention and control arms. In the S. aureus group, the intervention consisted of daily chlorhexidine showers and application of mupirocin nasal ointment twice a day for 5 days before surgery. In noncarriers, only chlorhexidine showers were prescribed. Sample size calculation was based on the initial trial for overall and not for the prosthetic surgery group. No PJI was found at 2 years in either the carrier or in the noncarrier group. Therefore, no definite conclusion about the efficacy of preoperative decolonization to reduce PJI can be drawn. PJI proportions in this study were lower than described in the literature (mostly around 0.3%). Despite the insufficient sample size, this trial is the largest randomized trial on decolonization with a long-term follow-up, and results may be helpful for future meta-analyses.

The oxacillin- and cefoxitin-susceptible

Decolonization with topical antimicrobials is frequently prescribed in health care and community settings to prevent Staphylococcus aureus infection. However, effects on commensal skin microbial communities remains largely unexplored. Within a household affected by recurrent methicillin-resistant S. aureus skin and soft tissue infections (SSTI), skin swabs were collected from the anterior nares, axillae, and inguinal folds of 14 participants at 1- to 3-month intervals over 24 months. Four household members experienced SSTI during the first 12-months (observational period) and were prescribed a 5-day decolonization regimen with intranasal mupirocin and bleach water baths at the 12-month study visit. We sequenced the 16S rRNA gene V1-V2 region and compared bacterial community characteristics between the pre- and post-intervention periods and between younger and older subjects. The median Shannon diversity index was stable during the 12-month observational period at all three body sites. Bacterial community characteristics (diversity, stability, and taxonomic composition) varied with age. Among all household members, not exclusively among the four performing decolonization, diversity was unstable throughout the year post-intervention. In the month after decolonization, bacterial communities were changed. Although communities largely returned to their baseline states, relative abundance of some taxa remained changed throughout the year following decolonization (e.g., more abundant

Bifidobacteria are typical commensals inhabiting the human intestine and are beneficial to the host because of their probiotic properties. One of the risks concerning probiotics is the potential of introducing antibiotic resistance genes (ARGs) to the host gut pathogens. This study was aimed to depict the general antibiotic resistance characteristics of the genus Bifidobacterium by combining the reported phenotype dataset and in silico genotype prediction. Bifidobacteria were mostly reported to be sensitive to beta-lactams, glycopeptides, chloramphenicol, and rifampicin, but resistant to aminoglycosides, polypeptides, quinolones, and mupirocin. Generally, the resistance phenotypes to erythromycin, tetracycline, fusidic acid, metronidazole, clindamycin, and trimethoprim were variable. Besides cmX and tetQ, characterized in bifidobacterial resident plasmids, 3520 putative ARGs were identified from 831 bifidobacterial genomes through BLASTP search. The identified ARGs matched thirty-eight reference ARGs, four of which seemed to be mutant housekeeping genes. The two high-abundant ARGs, tetW and ermX, were found to have different distribution traits. The predicted ARGs reasonably explained most of the corresponding resistant phenotypes in the published literature.

Summary Background The effects of subinhibitory concentrations (sub-MICs) of antibacterial agents on the biofilm-forming ability of Staphylococcus aureus require further study. Aim To investigate the effects of sub-MICs of chlorhexidine and mupirocin on biofilm formation in clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates. Methods MRSA isolates were collected from patients with bloodstream infections at a tertiary care hospital. The basal level of biofilm formation and biofilm induction by sub-MICs of chlorhexidine and mupirocin were evaluated by measuring biofilm mass stained with Crystal Violet. Findings Of the 112 MRSA isolates tested, 63 (56.3%) and 44 (39.3%) belonged to sequence type (ST)5 and ST72 lineages, respectively, which are the predominant healthcare- and community-associated clones in South Korea. ST5 isolates were more likely to have chlorhexidine MIC ≥4 (73.0% vs 29.5%), resistance to mupirocin (23.8% vs 0%), agr dysfunction (73.0% vs 9.1%), and qacA/B gene (58.7% vs 2.3%) compared to ST72 isolates. The basal level of biofilm formation ability was frequently stronger in ST72 isolates compared to ST5 isolates (77.3% vs 12.7%). Sub-MICs of chlorhexidine and mupirocin promoted biofilm formation in 56.3% and 53.6%, respectively, of all isolates. Biofilm induction was more prevalent in ST5 isolates (85.7% for chlorhexidine, 69.8% for mupirocin) than in ST72 isolates (15.9% for chlorhexidine, 27.3% for mupirocin). Conclusion Sub-MICs of chlorhexidine and mupirocin promoted biofilm formation in half of the clinical MRSA isolates. Our results suggest that ST5 MRSA biofilm can be induced together with some other bacterial virulent factors following exposure to chlorhexidine, which might confer a survival advantage to this clone in the healthcare environment.

Purpose Colonization of methicillin-resistant Staphylococcus aureus (MRSA) can be detected via nasal screens. Evidence indicates that negative MRSA nasal screens may be used to de-escalate anti-MRSA antibiotics in pulmonary infections. In the ICU, universal decolonization with intranasal mupirocin is implemented to reduce MRSA infection risk. This study aimed to determine whether mupirocin administration affects the reliability of MRSA PCR nasal screens. Methods This retrospective study divided subjects based on timing of intranasal mupirocin administration—before and after MRSA screen. Subjects with confirmed pulmonary infection that received vancomycin, blood/respiratory cultures, and had MRSA PCR screen collected were included. Subjects with concurrent infection requiring vancomycin or MRSA infection in prior 30 days were excluded. Primary outcome of this non-inferiority study was the negative predictive value (NPV) of the screen. Secondary outcomes included the positive predictive value (PPV), sensitivity, and specificity of the screen and duration of vancomycin. Results Ultimately, 125 subjects were included in each group. The NPV in the group receiving mupirocin before screen was 95.2%, whereas the NPV in the group receiving mupirocin after screen was 99%. The difference between groups was -3.8% (90% CI -7.8%-0.2%; p=0.31), which failed to meet non-inferiority criteria. The secondary outcomes of PPV, sensitivity and specificity of the screen were similar in both groups. The duration of vancomycin was significantly longer in subjects receiving mupirocin before screen (3 days vs. 2 days; p Conclusion Intranasal mupirocin prior to the screen may reduce NPV in pulmonary infections. Approach de-escalation of vancomycin based on screen results with caution.

Objectives To investigate the genetic characteristics associated with eradication failure of Staphylococcus aureus in infants below 90 days old. Methods S. aureus isolated from clinical specimen cultures (blood, surgical tissue, or drainage, pus, etc.) and routine screening cultures in the neonatal intensive care unit (nasal and axillary skin swab) from patients below 90 days old were collected prospectively for 1 year, from August 2017 to July 2018. The isolates underwent typing and screening for genes associated with chlorhexidine (qacA/B), quaternary ammonium (smr), and mupirocin resistance (iles mutation, mupA, mupB), as well as Panton-Valentine leukocidin (PVL) toxin. Results During the study period, 40 nonduplicate isolates were included for analyses, of which 70.0% were methicillin-resistant S. aureus (MRSA). Mupirocin resistance was found in 25% of the total isolates; 17.4% of the colonizers; and 35.3% of the pathogens (P = 0.196). Chlorhexidine resistance gene was found in 3 MRSA isolates colonized in the nares of preterm infants. All isolates harbored the disinfectant quaternary ammonium compound (QAC) resistance gene. PVL toxin gene was found in 57.5%, and the presence of PVL gene among colonizers and pathogens was similar (69.6% vs. 41.2%, P = 0.072). Conclusions Mupirocin, chlorhexidine, and QAC-resistant MRSAs harboring the PVL toxin gene were found in the nasal carriages of preterm infants. In this highly vulnerable patient population, one-fourth of the isolates harbored mupirocin-resistant genes, and all were resistant to QAC disinfectants. These strains are associated with persistence in both carriage and environmental reservoirs within the hospitals.

To evaluate the impact of active surveillance cultures (ASC) for Staphylococcus aureus (SA) and decolonization on the rate of infection in neonates in a neonatal intensive care unit (NICU). Using a quasi-experimental design with control groups, rates of SA infections before and after implementing weekly ASC and topical mupirocin decolonization in a level IV NICU were compared. Comparators were the rates of gram negative bloodstream infections (BSI) and of SA BSI at an affiliated NICU where the intervention was not implemented. There was a 77% (p

Background A household approach to decolonization decreases skin and soft tissue infection (SSTI) incidence, though this is burdensome and costly. As prior SSTI increases risk for SSTI, we hypothesized that the effectiveness of decolonization measures to prevent SSTI when targeted to household members with prior year SSTI would be noninferior to decolonizing all household members. Methods Upon completion of our 12-month observational Household Observation of Methicillin-resistant Staphylococcus aureus in the Environment (HOME) study, 102 households were enrolled in HOME2, a 12-month, randomized noninferiority trial. Pediatric index patients with community-associated methicillin-resistant Staphylococcus aureus (MRSA) SSTI, their household contacts, and pets were enrolled. Households were randomized 1:1 to the personalized (decolonization performed only by household members who experienced SSTI during the HOME study) or household (decolonization performed by all household members) approaches. The 5-day regimen included hygiene education, twice-daily intranasal mupirocin, and daily bleach-water baths. At 5 follow-up visits in participants’ homes, swabs to detect S. aureus were collected from participants, environmental surfaces, and pets; incident SSTIs were ascertained. Results Noninferiority of the personalized approach was established for the primary outcome 3-month cumulative SSTI: 23 of 212 (10.8%) participants reported SSTI in household approach households, while 23 of 236 (9.7%) participants reported SSTI in personalized approach households (difference in proportions, −1.1% [95% confidence interval, −6.7% to 4.5%]). In multivariable analyses, prior year SSTI and baseline MRSA colonization were associated with cumulative SSTI. Conclusions The personalized approach was noninferior to the household approach in preventing SSTI. Future studies should interrogate longer durations of decolonization and/or decontamination of the household environment to reduce household MRSA burden. Clinical Trials Registration NCT01814371.

Objectives There is conflicting data on the success of mupirocin as an effective decolonizing regimen forStaphylococcus aureus (SA) carriage, in part due to increasing drug resistance. This multi-center, randomized, open-label, prospective phase 1 study compared the safety and local tolerability of two nasal formulations of XF-73, a novel porphyrinic antibacterial drug with rapid intrinsic activity against SA. Methods The study was conducted in 2 dosing cohorts, and enrolled 60 healthy adults. In Part 1, 8 non-SA carriers were randomized to 2 groups of 4 subjects in each arm and were treated with the new formulations of XF-73 in concentrations of 0.5 mg/g 2% gel and 2 mg/g 2% gel, respectively. In Part 2, 52 healthy persistent SA carriers were randomized to 4 groups of 13 subjects in each arm and were treated with three different concentrations of XF-73 (0.5 mg/g 2% gel, 2 mg/g 2% gel and 0.5 mg/g 4% gel) or a 4% viscosified placebo gel, respectively. Plasma pharmacokinetics (PK) and pharmacodynamics (PD) studies were performed. Anti-staphylococcal activity was assessed as the presence or absence of SA and by quantification of the level of colonization using a semi-quantitative scale (SA score). Results 56 subjects (8/8 from Part 1 and 48/52 from Part 2) completed the study, with 47/60 comprising the PK population and 48/60 the PD population. There was no measurable systemic absorption of XF-73 from nasal application. Treatment with XF-73 was associated with a rapid diminution in the SA scores in all subjects. The most common treatment emergent adverse events (TEAE) reported were rhinorrhea and nasal dryness (15.5% each in Part 1 and Part 2). TEAEs were mostly mild and resolved spontaneously. Conclusion XF-73 was found to be safe and was tolerated with minimal side effects at doses of 0.5 mg/g 2% gel and 2 mg/g 2% gel in healthy volunteers. These findings support moving on to Phase 2 trials to further evaluate the efficacy of XF-73.

Background: Although the survival advantage of bilateral internal thoracic artery grafting (BITA) is well known in patients undergoing coronary artery bypass grafting (CABG), this technique has not been widely adopted. This is mainly because of the increased risk of deep sternal wound infections (DSWI) associated with its use. However, in recent years the overall risk of DSWI has decreased. This is mainly because of strategies that have been adopted to decrease the risk of these infections in patients undergoing CABG. Conclusion: In this review we identified DSWI preventive strategies and described them in detail so that their use by surgeons can be increased. This would minimize the risk of DSWI after BITA grafting and maximize the use of this highly effective surgical technique.

Resumen Introducción. Staphylococcus aureus resistente a la meticilina (SARM) es un microorganismo que coloniza las fosas nasales y diferentes partes del cuerpo, lo cual se considera un factor de riesgo para adquirir infecciones invasivas, especialmente en pacientes sometidos a cirugía cardiovascular. Objetivo. Determinar la colonización nasal por SARM y establecer las características clínicas en pacientes programados para cirugía cardiovascular. Materiales y métodos. Se hizo un estudio descriptivo entre febrero y diciembre de 2015. Se incluyeron pacientes adultos programados para cirugía cardiovascular en el Hospital Universitario San Ignacio de Bogotá. La colonización se identificó mediante reacción en cadena de la polimerasa (Polymerase Chain Reaction, PCR) en tiempo real en muestras obtenidas mediante hisopados nasales. Los pacientes fueron descolonizados con mupirocina al 2,0 % intranasal dos veces al día y baños con gluconato de clorhexidina al 4 % del cuello hacía abajo durante cinco días, al cabo de lo cual se hizo una PCR de control. Resultados. Se incluyeron 141 pacientes, 52 hospitalizados y 89 ambulatorios. Del total, 19 (13,4 %) tenían colonización nasal por SARM, correspondientes a 9 (17,3 %) de los 52 hospitalizados y 10 (11,2 %) de los 89 ambulatorios. Todos los pacientes sometidos a descolonización tuvieron resultado negativo en la PCR al final del proceso y ninguno presentó infección del sitio operatorio por S. aureus. Conclusiones. Se demostró colonización nasal por SARM tanto en los pacientes hospitalizados como en los ambulatorios. La descolonización con mupirocina fue efectiva para erradicar el estado de portador a corto plazo, lo que podría tener efecto en las tasas de infección del sitio operatorio en las cirugías cardiovasculares. Abstract Introduction: Methicillin-resistant Staphylococcus aureus (MRSA) is a microorganism that colonizes nostrils and different parts of the body, which is considered a risk factor to acquire invasive infections, especially in cardiovascular surgery patients. Objective: To determine the frequency of nasal colonization by MRSA and to establish the clinical characteristics in patients scheduled for cardiovascular surgery. Materials and methods: This was a descriptive study conducted between February and December, 2015. We included adult patients scheduled for cardiovascular surgery at the Hospital Universitario San Ignacio in Bogotá, Colombia. Colonization was identified by real-time PCR from nasal swabs. Colonized patients were treated with mupirocin 2.0% intranasally twice a day and bathed with chlorhexidine 4% from the neck downwards for five days. At the end of this treatment, PCR control was carried out. Results: We included 141 patients with a percentage of nasal colonization of 13.4% (19/141). There were 52 hospitalized patients and 89 outpatients with a percentage of nasal colonization of 17.3% (9/52), and 11.2% (10/89), respectively. All colonized patients who received treatment had a negative PCR at the end of the regime and none of the participating patients had a surgical site infection by S. aureus at the end of the study. Conclusions: Nasal colonization was observed both in hospitalized patients and outpatients. Decolonization treatment with mupirocin was effective to eradicate the carrier state in the short term, which could impact the rates of surgical wound infection associated with cardiovascular surgery.