A decolonization protocol normally used in older patients was associated with a sharp reduction in methicillin-resistant Staphylococcus aureus (MRSA) infections in critically ill infants, providers at Children's Hospital New Orleans reported today at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
The protocol, which involved bathing infants in the hospital's intensive care units (ICUs) with an antiseptic wash and swabbing their nostrils with a topical antibiotic ointment, was implemented more than a year into the COVID-19 pandemic, partly in response to a rise in MRSA cases. When compared with the pre-implementation period, cases of hospital-onset MRSA and MRSA bacteremia in the units fell by 41% and 54%, respectively.
The lead presenter of the study says she believes the protocol, if implemented in other pediatric critical care settings, could achieve similar results.
"We're hoping that they would see the same outcomes that we had," Jennifer Schroeder, MPH, lead infection preventionist at Children's Hospital New Orleans, told CIDRAP News.
A significant concern in pediatric ICUs
Schroeder said she and her colleagues had been thinking about a MRSA decolonization strategy for their cardiac, neonatal, and pediatric ICUs prior to the COVID-19 pandemic. The only decolonization measure they used was for patients with central lines, who received a bath with soap, water, and the antiseptic chlorhexidine gluconate (CHG). They knew, though, that this wasn't enough, since many children in these units are at risk for MRSA.
In 2019, the health system of which Children's Hospital New Orleans is a member designed a MRSA decolonization protocol for all of its critical care units. But the protocol did not include children under the age of 2 years, which posed a problem.
"At any given time, two of those three units are all babies under the age of 2, so we would be excluding over half of my population in need," she said.
MRSA typically causes skin and other soft-tissue infections that can be treated with antibiotics, but it's a significant concern in critically ill young children. MRSA infections in pediatric and neonatal ICUs are associated with significant morbidity and mortality, particularly when the infection gets into the bloodstream. "We've noticed with our tiny patients, specifically our neonatal population, that if they get a MRSA infection, it spreads very quickly to becoming bacteremic," Schroeder said.
When MRSA cases began to rise across the entire health system during the pandemic, Schroeder and her colleagues revisited the issue. For all patients 2 years and older, they implemented the protocol designed by the health system—a daily CHG bath and twice-daily use of a nasal antiseptic.
In patients under 2, the protocol involved a daily CHG bath and 5 days of applying the topical antibiotic mupirocin in the nostrils (a common part of the body for Staph bacteria to colonize). The protocol was implemented on admission and then monthly thereafter.
From January 2021 to October 2021 (the pre-intervention phase), they took time to familiarize the staff with the protocol and add it to the electronic medical record. They then implemented the intervention in all critical care units from November 2021 to August 2022 (the post-intervention phase). To evaluate the impact of the intervention, they compared MRSA and MRSA bacteremia rates during the two periods.
Despite an increase in admissions and patient-days during the post-intervention period (from 2,316 admissions and 15,765 patient-days pre-intervention to 2,778 admissions and 17,296 patient-days), the hospital-onset MRSA rate per 1,000 patient-days fell from 1.459 to 0.867—a 41% decline—while the hospital-onset MRSA bacteremia rate fell from 0.381 to 0.173—a 56% decline. In addition, the average length of stay fell from 6.8 to 6.2 days.
This has been huge for us.
Schroeder said the MRSA reduction was even greater in individual units. The cardiac ICU saw an 86% reduction in hospital-onset MRSA cases post-intervention, and saw no cases of MRSA bacteremia. Because the protocol was so successful, it's been continued in all of the hospital's pediatric critical care units, and none have reported a case of hospital-onset MRSA bacteremia in 2023.
"This has been huge for us," Schroeder said.
Protocol could cut costs, antibiotic exposure
Schroeder said the dramatic reduction in MRSA infections could also lead to reductions in deaths, hospital stays, and healthcare costs. She noted that a hospital-onset MRSA infection costs around $14,000 on average, while the costs of a tube of mupirocin is just a few dollars.
In addition, the protocol could significantly reduce antibiotic exposure in critically ill pediatric patients, which she would like to avoid.
"In teeny-tiny patients, we really get concerned about acute kidney injury when we use antibiotics, specifically ones targeted toward MRSA," she said.
We hope their success inspires others to implement similar initiatives.
In a press release, APIC President Patricia Jackson, RN, hailed the effort to show the utility of nasal decolonization in the pediatric setting.
"We hope their success inspires others to implement similar initiatives," she said.
