title: Targeted versus universal decolonization to prevent ICU infection.
abstract: 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).
authors.affiliation: University of California Irvine School of Medicine, Orange, CA 92868, USA. sshuang@uci.edu
authors.forename: Susan S
authors.initials: SS
authors.lastname: Huang
authors.forename: Edward
authors.initials: E
authors.lastname: Septimus
authors.forename: Ken
authors.initials: K
authors.lastname: Kleinman
authors.forename: Julia
authors.initials: J
authors.lastname: Moody
authors.forename: Jason
authors.initials: J
authors.lastname: Hickok
authors.forename: Taliser R
authors.initials: TR
authors.lastname: Avery
authors.forename: Julie
authors.initials: J
authors.lastname: Lankiewicz
authors.forename: Adrijana
authors.initials: A
authors.lastname: Gombosev
authors.forename: Leah
authors.initials: L
authors.lastname: Terpstra
authors.forename: Fallon
authors.initials: F
authors.lastname: Hartford
authors.forename: Mary K
authors.initials: MK
authors.lastname: Hayden
authors.forename: John A
authors.initials: JA
authors.lastname: Jernigan
authors.forename: Robert A
authors.initials: RA
authors.lastname: Weinstein
authors.forename: Victoria J
authors.initials: VJ
authors.lastname: Fraser
authors.forename: Katherine
authors.initials: K
authors.lastname: Haffenreffer
authors.forename: Eric
authors.initials: E
authors.lastname: Cui
authors.forename: Rebecca E
authors.initials: RE
authors.lastname: Kaganov
authors.forename: Karen
authors.initials: K
authors.lastname: Lolans
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Perlin
authors.forename: Richard
authors.initials: R
authors.lastname: Platt
mesh_terms: D000328:Adult; D000368:Aged; D016470:Bacteremia / Q000523:psychology; D001494:Baths; D002353:Carrier State / Q000175:diagnosis*; D002710:Chlorhexidine / Q000009:adverse effects / Q000627:therapeutic use; D057186:Comparative Effectiveness Research; D003428:Cross Infection / Q000517:prevention & control* / Q000635:transmission; D018562:Disease Transmission, Infectious / Q000517:prevention & control; D004203:Disinfection / Q000379:methods*; D005260:Female; D006801:Humans; D017053:Infection Control / Q000379:methods*; D007362:Intensive Care Units; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification; D008875:Middle Aged; D016712:Mupirocin / Q000009:adverse effects / Q000627:therapeutic use; D009296:Nasal Cavity / Q000382:microbiology; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000517:prevention & control* / Q000635:transmission
chemical_list: D016712:Mupirocin; D002710:Chlorhexidine