Hi
May I ask
when a patient is infected by MRSA invasive infection, is there a role of doing nasal swab in the patients as the new NHS guideline released in 2015 (Dumfries and Galloway) did not specifically state whether perianal and nasal swabs need to be taken unlike the recommendation for those with positive wound swab whereby the above needed to done for the patients with wound
As such, do we do it and give chlorhexidine regardless of the result and if the result + then the patient is prescribed mupirocin or we give both chlorhexidine and mupirocin without doing the swab to reduce the cost of nasal swab and use of chromogenic agar
Will this approach then cost us the mupirocin resistance ?
My next question is, if a patient is treated with IV vancomycin , can that eradicate the MRSA colonisation state as the data from clinical study state the AUC/MIC more than 850 needed to be achieved for this in the VAP study. This value is just way too high to be achieved in clinical practice
Hello. Ok.. I'm not sure I understand properly your questions. Any way, I'll try to answer my best.
I think nasal swabs are crucial to control and prevent an MRSA diffusion. Not only to monitor the infected patient but mostly to prevent a spread. Also with nasal swabs you can monitor the infected patient during the therapy, nasal swabs + wound swabs (or sample positive for the infection). Eradicate an infection is possible, more difficult is to eradicate a colonization. Vancomicin, I'd suggest it only as a "last chance", give a chance to linezolid instead. Just to prevent other resistance development.
Hoping to be helpful.
Hi. As Dra. Pezzotta explains above, erradicating colonization is much more difficult that treating an active infections. Probably nasal and wound swabs remain useful tools to rule out colonization; local mupirocin is an option in those cases.
I hope it helps you
Hi all,
Thanks for the answers
Reason I am asking is because
1) cost: which is prohibitive for our patients to have the swabs done
for colonisation study single swab will cost patient about USD 30
and for a patient without wound a single nasal swab will detect 2/3 (70%) of the carriers and add in perineal swab it would increase to about 90% (correct me if I am wrong)
as such that would be USD 30 x 2
If a patient has wound of IJC for say ESRD that would be ad additional swab to wound or exit sites: sum would be USD 30 x 3
As such my questions would be
Should we just decolonise them anyway (patients with MRSA invasive infections i.e. bacteremia) and not doing the swabs since the cost would be huge to my patients:
Meaning 5 days mupirocin ointment + 5 days chlorhexidine bath
or
do we swab and treat accordingly
both of which we need to repeat the swabs after 48 H of decolonisation and 3 consecutive swabs 48 H apart need to be negative to say that a patient is negative
Which algorithm would it be ok
2) my next question is more of a research question
if I treat a bacteraemic patients with MRSA with vancomycin which by definition would at least be 14 days
does the prolong therapy then kill the bacteria as the MRSA is exposed to some level of vancomycin at the nasal area
is there any data out there to answer this Q
Regards
Helmi..
Ok. That's huge problem. I think antibiotic therapy would cost, at least, far more then some swabs. I would probably choose a single nasal swab to establish if colonized or not, ONLY on some specific patients. This should be: pre-surgery patients, infected patients after therapy, patiens coming from another hospital and ONLY the patients who are in intensive care unit (or have been) or in some critical departiment, such as oncohaemathology or transplant. Select your patients to be sure you use the screening procedure only if restrictly necessary. Do not try a decolonization on everyone, mostly if they are not in the risck category.
As you said: This is correct but you can manage it with some arrangament if you have problems with the costs. Decolonization do it only if is necessary, I mean if it is an effective risck for the patient. Repeat the swab 48h after an then only another one before the dimission. Use PCT (procalcitonin) to establish firts if you have a real bacterial infection, then weather or not the therapy of the infection has worked.
Then... After 14 days Vancomycin you cannot be sure that the colonization has gone as the infection. I don't have any specific data, but as I told colonization is difficult to remove, it depends on many different factor such as: predisposition, habit, enviroment, ect... Just be focus on the restrictly necessary therapy of the proved infection. This will allow you to save more money and to prevent other resistance development. This also for the patients economy. The more you treat the more they'll risck to have other resistance bacteria, the more they'll need to be checked, the more they'll spend.
This is my opinion. Spend a 'lil bit more now for a check would prevent to spend too much later, on therapy and other screening or hospitalizations.
Good Luck.
Ramona.
Thanks Ramona for your prompt answer and opinion...
they really helped... :)
Thanks again
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