have been suboptimal for many years, and efforts to improve them have had little impact on
compliance rates, which average about 40%. Risk factors for poor compliance include being a
physician or a nursing assistant, working in an ICU, working during weekdays performing
activities with a high risk for transmission, and having many opportunities for hand hygiene
per hour of patient care (81). Most of these risk factors for poor hand hygiene are commonly
present in ICUs.
HCWs must be taught to decontaminate their hands with an antiseptic-containing agent
(an alcohol-based hand rub or a hand-washing preparation containing an antiseptic agent). If
hands are visibly soiled with urine, feces, blood, or other body fluids, they must be washed
with soap and water followed by application of an alcohol-based hand rub or washed with
soap containing an antiseptic.
Hands must be decontaminated before and after contact with each patient. This includes
decontamination by washing with an antimicrobial soap or application of an alcohol-based
hand rub after removal of gloves (106). HCWs should be strongly encouraged to apply
moisturizing hand lotions, but it is important to establish that such preparations are
compatible with the cleansing products and glove materials used by the HCWs. They must be
thoroughly educated about microbial contamination of their hands and why hand hygiene is
important. Hand hygiene should be monitored and feedback should be given to the HCWs
about their performance on a continuous basis. It is unlikely that occasional feedback will
change hand-hygiene practice.
Decolonization of Patients Who Are Carriers of MRSA
Decolonization of patients as a way to prevent and control outbreaks of colonization and
infections due to both MRSA and MSSA has been studied for decades. In spite of the introduction
of mupirocin as one of the most potent topical anti-staphylococcal antibiotics discovered to date,
decolonization of patients colonized with MRSA remains a challenge (107). In a number of
studies, patients often become recolonized with the same or a different strain of MRSA. Few
randomized controlled clinical trials with long-term follow-up (12 seeks after intranasal
application of mupirocin) have been conducted. Decolonization is often attempted using a
combination of mupirocin applied to the nares and showers with an antiseptic agent such as
chlorhexidine. Very little published data suggest that chlorhexidine baths may add to the efficacy
of mupirocin (108). One of the major problems in the use of mupirocin for decolonization of
patients, in addition to failure to maintain long-term decolonization, is development of resistance
(109). Resistance is particularly likely to develop with extensive use such as application to
wounds. Resistance to mupirocin after use for treatment of both colonization and infection can be
effectively controlled by limiting its use to the treatment of colonization (109).
Use of mupirocin for decolonization of patients in ICUs must be very judicious. Several
of the risk factors for failure are present in many ICU patients (107). These include
(i) colonization of multiple body sites; (ii) chronic non-healing wounds; and (iii) the presence of
colonized foreign bodies such as tracheostomy tubes or gastrostomy tubes. Treatment
for colonization should be limited to the nares. Attempts at decolonization of patients with
colonization at multiple body sites, with chronic non-healing wounds, and the presence of
foreign bodies should be avoided. If mupirocin is used on multiple patients over long periods
of time (months), MRSA isolates from patients should be tested for susceptibility to mupirocin.
Another approach to decolonization of MRSA carriers has been instillation of
vancomycin into the gastrointestinal tract by way of a nasogastric tube. In one study, the
ICU patients had surveillance cultures of throat and rectum for MRSA over an eight-month
period (110). The patients were part of a study of prevention of infection in mechanically
ventilated patients. The patients were receiving oral antimicrobial agents for selective
decontamination of the digestive tract. The authors designed a study to determine whether
oral administration of vancomycin could eliminate MRSA from the intestinal tract. The study
was not randomized and did not have concurrent controls. The authors noted a significant
decrease in MRSA infections in the treated group compared with the historical group. They
were able to show elimination of MRSA from the gastrointestinal tract based on rectal swab
cultures. The weaknesses of the study included nonrandomization, the use of historic controls,
MRSA/VRE Colonization and Infection in the Critical Care Unit 109