title: Effect of body surface decolonisation on bacteriuria and candiduria in intensive care units: an analysis of a cluster-randomised trial.
abstract: BACKGROUND
  Urinary tract infections (UTIs) are common health-care-associated infections. Bacteriuria commonly precedes UTI and is often treated with antibiotics, particularly in hospital intensive care units (ICUs). In 2013, a cluster-randomised trial (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) showed that body surface decolonisation reduced all-pathogen bloodstream infections. We aim to further assess the effect of decolonisation on bacteriuria and candiduria in patients admitted to ICUs.
  
  
  METHODS
  We did a secondary analysis of a three-group, cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The three groups included were either meticillin-resistant Staphylococcus aureus (MRSA) screening and isolation, targeted decolonisation (screening, isolation, and decolonisation of MRSA carriers) with chlorhexidine and mupirocin, and universal decolonisation (no screening, all patients decolonised) with chlorhexidine and mupirocin. Protocol included chlorhexidine cleansing of the perineum and proximal 6 inches (15·24 cm) of urinary catheters. ICUs within the same hospital were assigned the same strategy. Outcomes included high-level bacteriuria (≥50 000 colony forming units [CFU]/mL) with any uropathogen, high-level candiduria (≥50 000 CFU/mL), and any bacteriuria with uropathogens. Sex-specific analyses were specified a priori. Proportional hazards models assessed differences in outcome reductions across groups, comparing an 18-month intervention period to a 12-month baseline period.
  
  
  RESULTS
  122 646 patients (48 390 baseline, 74 256 intervention) were enrolled. Intervention versus baseline hazard ratios (HRs) for high-level bacteriuria were 1·02 (95% CI 0·88-1·18) for screening or isolation, 0·88 (0·76-1·02) for targeted decolonisation, and 0·87 (0·77-1·00) for universal decolonisation (no difference between groups, p=0·26), with no sex-specific reductions (HRs for men: 1·09 [95% CI 0·85-1·40] for screening or isolation, 1·01 [0·79-1·29] for targeted decolonisation, and 0·78 [0·63-0·98] for universal decolonisation, p=0·12; HRs for women: 0·97 [0·80-1·17] for screening and isolation, 0·83 [0·70-1·00] for targeted decolonisation, and 0·93 [0·79-1·09] for universal decolonisation, p=0·49). HRs for high-level candiduria were 1·14 (0·95-1·37) for screening and isolation, 0·99 (0·83-1·18) for targeted decolonisation, and 0·83 (0·70-0·99) for universal decolonisation (p=0·05). Differences between sexes were due to reductions in men in the universal decolonisation group (HRs: 1·21 [95% CI 0·88-1·68] for screening or isolation, 1·01 [0·73-1·39] for targeted decolonisation, and 0·63 [0·45-0·89] for universal decolonisation, p=0·02). Bacteriuria with any CFU/mL was also reduced in men in the universal decolonisation group (HRs 1·01 [0·81-1·25] for screening or isolation, 1·04 [0·83-1·30] for targeted decolonisation, and 0·74 [0·61-0·90] for universal decolonisation, p=0·04).
  
  
  CONCLUSIONS
  Universal decolonisation of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin could be a potential preventive strategy in male patients because it significantly decreases candiduria and any bacteriuria, but not for women.
  
  
  BACKGROUND
  HAI Program from AHRQ, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, CDC Prevention Epicenters Program.
authors.affiliation: Division of Infectious Diseases, University of California Irvine School of Medicine, Orange, CA, USA. Electronic address: sshuang@uci.edu.
authors.forename: Susan S
authors.initials: SS
authors.lastname: Huang
authors.affiliation: Clinical Services Group, Hospital Corporation of America, Houston, TX; Division of Infectious Diseases, Texas A&M Health Science Center College of Medicine, Houston, TX, USA.
authors.forename: Edward
authors.initials: E
authors.lastname: Septimus
authors.affiliation: Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA.
authors.forename: Mary K
authors.initials: MK
authors.lastname: Hayden
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors.forename: Ken
authors.initials: K
authors.lastname: Kleinman
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Sturtevant
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors.forename: Taliser R
authors.initials: TR
authors.lastname: Avery
authors.affiliation: Nashville, TN, USA.
authors.forename: Julia
authors.initials: J
authors.lastname: Moody
authors.affiliation: Nashville, TN, USA.
authors.forename: Jason
authors.initials: J
authors.lastname: Hickok
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors.forename: Julie
authors.initials: J
authors.lastname: Lankiewicz
authors.affiliation: Division of Infectious Diseases, University of California Irvine School of Medicine, Orange, CA, USA.
authors.forename: Adrijana
authors.initials: A
authors.lastname: Gombosev
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors.forename: Rebecca E
authors.initials: RE
authors.lastname: Kaganov
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Haffenreffer
authors.affiliation: Office of HAI Prevention Research and Evaluation, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: John A
authors.initials: JA
authors.lastname: Jernigan
authors.affiliation: Nashville, TN, USA.
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Perlin
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Platt
authors.affiliation: Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA; Department of Medicine, Cook County Health and Hospitals System, Chicago, IL, USA.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Weinstein
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000891:Anti-Infective Agents, Local / Q000627:therapeutic use*; D001437:Bacteriuria / Q000382:microbiology / Q000517:prevention & control; D002175:Candida / Q000302:isolation & purification; D002177:Candidiasis / Q000382:microbiology / Q000517:prevention & control* / Q000652:urine; D002353:Carrier State / Q000188:drug therapy* / Q000382:microbiology / Q000517:prevention & control; D002710:Chlorhexidine / Q000627:therapeutic use; D016000:Cluster Analysis; D004203:Disinfection / Q000379:methods; D005260:Female; D006801:Humans; D017053:Infection Control / Q000379:methods; D007362:Intensive Care Units; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000187:drug effects; D008875:Middle Aged; D016712:Mupirocin / Q000627:therapeutic use; D012737:Sex Factors; D014552:Urinary Tract Infections / Q000382:microbiology / Q000517:prevention & control* / Q000652:urine
chemical_list: D000900:Anti-Bacterial Agents; D000891:Anti-Infective Agents, Local; D016712:Mupirocin; D002710:Chlorhexidine