Q&A: Antiseptic Soap and Nasal Decolonization

COMMENTARY

Susan Huang, MD, MPH

DISCLOSURES

Disclosure: Susan Huang, MD, MPH, has disclosed the following relevant financial relationships: Conducted studies in which Xttrium Laboratories contributed antiseptic products to participating nursing home and hospital patients

Editorial Collaboration

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More than 1.3 million people are cared for in nursing homes each year. These individuals have complex health needs and often require skilled nursing care and rehabilitation services. Many are medically fragile and quite vulnerable to infection, as was made evident during the COVID-19 pandemic. Many of our currently available interventions to prevent the spread of multidrug-resistant organisms (MDROs) and MDRO infections are costly and challenging to implement, which can limit their effectiveness, particularly in the nursing home setting. Well-defined, evidence-based interventions, supported by data collected in nursing homes, are critical to protecting residents. The recently published PROTECT trial provides a relatively simple strategy to reduce infections, hospitalizations, and MDRO carriage among nursing home residents. Key takeaway points from this trial are provided below.

The PROTECT trial was a 28–nursing home pragmatic cluster-randomized trial jointly led by Loren G. Miller, MD, MPH, investigator at the Lundquist Institute for Biomedical Innovation and associate chief of infectious diseases at Harbor-UCLA Medical Center; and Susan Huang, MD, MPH, Chancellor's Professor in the Division of Infectious Diseases at the University of California, Irvine School of Medicine. UC Irvine is a Centers for Disease Control and Prevention (CDC) Prevention Epicenters Program partner, and CDC supports its work evaluating the use of chlorhexidine bathing to reduce harms from MDROs in nursing home residents.

The trial assessed whether a topical antiseptic soap and nasal ointment regimen given to all residents ("universal decolonization") could reduce infections, hospitalizations, and carriage of MDROs when compared with routine care. The "cluster-randomized" design meant that entire nursing homes, rather than individual residents, were randomly assigned to universal decolonization or routine care. This design allowed the evaluation of a quality improvement strategy that would be implemented across an entire nursing home. The trial involved nearly 14,000 residents who had an average age of 76 years and spent an average of 250 days in the nursing home. All 28 participating nursing homes were located in Southern California and provided skilled nursing and rehabilitative care.

Prior to the intervention assignment, the hospitalization rate in participating nursing homes was 3.5 per 1000 resident days. This represents approximately 10.5 residents per month being hospitalized for any reason in a usual nursing home with 100 residents. Overall, 62% of admissions were due to infection. This high rate of serious infection and hospitalization is exactly why the PROTECT trial was conducted.

In addition, MDROs are common in nursing homes. On the basis of nasal and skin (axilla and groin) sampling in the PROTECT trial, half of residents had one or more MDROs. The most common MDROs were methicillin-resistant Staphylococcus aureus (MRSA; 37% carriage), extended-spectrum beta-lactamase producers (ESBL; 16%), and vancomycin-resistant Enterococcus (VRE; 6%). The high prevalence of MRSA was why an intervention strategy was selected that could reduce MRSA by decreasing carriage in the nose, the main reservoir for S aureus.

The 28 participating nursing homes were randomly assigned to one of two groups:

These materials are available to aid with implementation:

Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265. Source

Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368:533-542. Source

Huang SS, Singh R, McKinnell JA, et al. Decolonization to reduce postdischarge infection risk among MRSA carriers. N Engl J Med. 2019;380:638-650. Source

Milstone AM, Elward A, Song X, et al. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. Lancet. 2013;381:1099-1106. Source

Huang SS, Septimus E, Kleinman K, et al. Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster-randomised trial. Lancet. 2019;393:1205-1215. Source

Public Information from the CDC and Medscape