Using mupirocin ointment to reduce <I>staphylococcus aureus</I> infection rates in people who are nasal carriers of <I>staphylococcus aureus. </I>

van Rijen M, Bonten M, Wenzel R, Kluytmans J

Published Online:

February 16, 2011

Staphylococcus aureus (S. aureus) is the main hospital acquired pathogen and although the focus has been on preventing cross-infection between patients, it has been shown that a large number of S. aureus infections start from the patient's own flora. Nasal carriage of S. aureus is a risk factor for infection in hospital patients and using a local antibiotic treatment of mupirocin ointment is often used to eradicate nasal S.aureus. It has been found that if people are nasal carriers of S. aureus then using mupirocin ointment reduces the level of S aureus infections.

Abstract (click to read)

Background:

Staphylococcus aureus (S. aureus) is the leading nosocomial (hospital acquired) pathogen in hospitals throughout the world. Traditionally, control of S. aureus has been focused on preventing cross-infection between patients, however, it has been shown repeatedly that a large proportion of nosocomial S. aureus infections originate from the patient's own flora. Nasal carriage of S. aureus is now considered a well defined risk factor for subsequent infection in various groups of patients. Local antibiotic treatment with mupirocin ointment is often used to eradicate nasal S. aureus.

Objectives:

To determine whether the use of mupirocin nasal ointment in patients with identified S. aureus nasal carriage reduced S. aureus infection rates.

Search strategy:

For this first update we searched the Cochrane Wounds Group Specialised Register (searched 9 September 2010); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library 2010 Issue 3; Ovid MEDLINE (2007 to September Week 1 2010); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, September 10, 2010);Ovid EMBASE (2007 to 2010 Week 36); and EBSCO CINAHL (2007 to 10 September 2010). No language or publication restrictions were applied.

Selection criteria:

Randomised controlled trials (RCTs) comparing nasal mupirocin with no treatment or placebo or alternative nasal treatment in the prevention of S. aureus infections in nasal S. aureus carriers were included.

Data collection and analysis:

Titles, abstracts and full-text articles of studies retrieved from the search process were independently assessed by two authors for inclusion. From included studies a data extraction form was made and the quality of the trial was assessed. The primary outcome was the S. aureus infection rate (any site). Secondary outcomes were time to infection, mortality, adverse events and infection rate caused by micro-organisms other than S. aureus.

Main results:

Nine RCTs involving 3396 participants met the inclusion criteria. Patient populations varied and several types of nosocomial S. aureus infection were described including bacteraemia, exit-site infections, peritonitis, respiratory tract infections, skin infections, surgical site infections (SSI) and urinary tract infections. After pooling the eight studies that compared mupirocin with placebo or with no treatment, there was a statistically significant reduction in the rate of S. aureus infection associated with intranasal mupirocin (RR 0.55, 95% CI 0.43 to 0.70).

A planned subgroup analysis of surgical trials demonstrated a significant reduction in the rate of nosocomial S. aureus infection rate associated with mupirocin use (RR 0.55, 95% CI 0.34 to 0.89) however this effect disappeared if the analysis only included surgical site infections caused by S. aureus (RR 0.63, 95% CI 0.38 to 1.04), possibly due to a lack of power. The infection rate caused by micro-organisms other than S. aureus was significantly higher in patients treated with mupirocin compared with control patients (RR 1.38 95% CI 1.118 to 1.72).

Authors' conclusions:

In people who are nasal carriers of S. aureus, the use of mupirocin ointment results in a statistically significant reduction in S. aureus infections.

This record should be cited as:

van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006216. DOI: 10.1002/14651858.CD006216.pub2

Assessed as up to date:

September 27, 2010

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Primary Review Group:

Wounds Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is mupirocin ointment in reducing infections in patients who are nasal carriers of Staphylococcus aureus (S. aureus)?

Bottom line:

Compared to placebo, mupirocin ointment produces a statistically significant reduction in S. aureus infections in nasal carriers. Short term use (up to 7 days) does not seem to be associated with resistance. Intranasal mupirocin should be considered for use in proven nasal carriers of S. aureus in hospitalised surgical, dialysis and non-surgical patient groups at risk of infection.

Caveat:

Only 2 trials, 1 with 72 participants and the other with 20 participants, were included in this review. The second study failed to report several methodological items and was inconsistent in its reporting of the outcomes measured.

Context:

S. aureus is the leading nosocomial (hospital-acquired) pathogen in hospitals throughout the world. Traditionally, control of S. aureus has been focused on preventing cross-infection between patients. However, it has been shown repeatedly that a large proportion of nosocomial S. aureus infections originate from the patient’s own flora. Nasal carriage of S. aureus is now considered a well-defined risk factor for subsequent infection in various groups of patients. Local antibiotic treatment with mupirocin ointment is often used to eradicate S. aureus. Until now, routine use of mupirocin has not been applied in many hospitals, mainly due to concern about the development of mupirocin resistance and the absence of convincing evidence that it reduces the infection rate.

Cochrane Systematic Review:

Van Rijen M et al. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Reviews 2008, Issue 4. Article No. CD006216. DOI: 10.1002/14651858.CD006216.pub2. This review contains 9 trials involving 3396 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Infectious disease > Infection control

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Using mupirocin ointment to reduce <I>staphylococcus aureus</I> infection rates in people who are nasal carriers of <I>staphylococcus aureus. </I>

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