In non-critical care patients, universal chlorhexidine bathing and targeted mupirocin for methicillin-resistant Staphylococcus aureus (MRSA) carriers did not reduce multidrug-resistant organisms significantly, according to the results of the active bathing to eliminate infection (ABATE Infection) trial (ClinicalTrials.gov, number NCT02063867) trial published the Lancet.
The ABATE Infection trial was a cluster-randomized trial of 53 hospitals and included a 12-month baseline period followed by a 2-month phase in period and a 21-month intervention period. Participating hospitals were randomly assigned to either routine care or daily chlorhexidine bathing for all patients in non-intensive care units (non-ICU) plus mupirocin for known MRSA carriers. During the intervention period, 156,889 patients were assigned to routine care and 183,013 were assigned to chlorhexidine bathing and mupirocin.
Results of the primary study outcome of MRSA or vancomycin-resistant enterococcus (VRE) clinical cultures attributed to participating units showed the hazard ratio for the intervention period vs the baseline period was 0.79 (0.73-0.87) in the decolonization group vs 0.87 (95% CI, 0.79-0.95) in the routine care group. There were no significant differences in the relative hazard ratios (P =.17) and adverse events were reported in <1% of the decolonization group, all of which involved chlorhexidine bathing not mupirocin.
It is important to note that this study population consisted of patients in settings where less than 3% had a known history of MRSA or VRE, and different results may be expected in populations with a higher prevalence or risk. The study investigators also noted that although they could accurately document that daily chlorhexidine bathing occurred, there was less assurance about the quality of chlorhexidine application. In addition, although a post-hoc analysis did find benefit of decolonization in a subgroup of patients with medical devices, the original design of the trial was not powered for this evaluation.
The results of this study revealed that “universal daily chlorhexidine bathing plus nasal decolonization for MRSA carriers does not reduce MRSA or VRE clinical cultures and all-cause bloodstream infections in patients in the general non-ICU population.” This finding is in contrast to similar trials done in several ICUs and previous single-center, quasiexperimental studies in non-ICU settings. The post-hoc analysis findings of a significant 37% reduction in MRSA and VRE and a significant 31% reduction in all-cause bloodstream infections in the subpopulation of patients with medical devices is encouraging but “further research is needed to confirm these effects if the decolonization strategy is applied only to patients with medical devices, since the ABATE Infection trial involved universal decolonization in all patients.”
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.