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Decolonization in Adult ICUs With Nasal Iodophor Antiseptic vs Nasal Mupirocin Antibiotic

In the Mupirocin-Iodophor ICU Decolonization Swap Out Trial, nasal iodophor antiseptic used during daily chlorhexidine gluconate (CHG) bathing in adults in intensive care units (ICUs) did not meet predetermined noninferiority criteria in comparison with nasal mupirocin antibiotic in adult ICU patients, researchers report. “In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin,” the authors add.

Conducted in U.S. community hospitals that were all using mupirocin-CHG for universal decolonization in ICUs at baseline, the 2-group, noninferiority, pragmatic trial cluster-randomized 137 randomized hospitals during baseline (May 2015–Apr. 2017) and intervention (Nov. 2017–Apr. 2019) periods to switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline) for universal decolonization in ICUs.

Based on ICU-attributable Staphylococcus aureus clinical cultures (primary outcome), methicillin-resistant S. aureus (MRSA) infection clinical cultures, and all-cause bloodstream infections, the study showed the following: “Among the 801,668 admissions in 233 ICUs, the participants’ mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, −0.9% [95% CI, −9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]).”

Source: JAMA